Provider Demographics
NPI:1760662589
Name:POWELL, RANDY MONROE (MED)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:MONROE
Last Name:POWELL
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 SW COZY LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9321
Mailing Address - Country:US
Mailing Address - Phone:360-876-3113
Mailing Address - Fax:253-396-5913
Practice Address - Street 1:3834 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2016
Practice Address - Country:US
Practice Address - Phone:253-396-5919
Practice Address - Fax:253-396-5913
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60145921101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00009805OtherDEPARTMENT OF HEALTH