Provider Demographics
NPI:1790701605
Name:POWELL, TIMOTHY A (LCSW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:POWELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 VALERIE CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-2040
Mailing Address - Country:US
Mailing Address - Phone:817-277-8225
Mailing Address - Fax:
Practice Address - Street 1:3013 VALERIE CT
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-2040
Practice Address - Country:US
Practice Address - Phone:817-277-8225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX176121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88653QOtherBLUE CROSS BLUE SHEILD
TX148929606Medicaid
TX148929602Medicaid
TX148929602Medicaid
TX88017HMedicare PIN