Provider Demographics
NPI:1790867943
Name:POWELL, LISA SENAVININ (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:SENAVININ
Last Name:POWELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 STEVENS AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1042
Mailing Address - Country:US
Mailing Address - Phone:502-558-5428
Mailing Address - Fax:502-459-8001
Practice Address - Street 1:1603 STEVENS AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1042
Practice Address - Country:US
Practice Address - Phone:502-558-5428
Practice Address - Fax:502-459-8001
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1267103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent