Provider Demographics
NPI:1821547894
Name:THOMAS POWELL, PHYLLIS (BS)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:THOMAS POWELL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 FOUR SEASONS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-2326
Mailing Address - Country:US
Mailing Address - Phone:813-803-0315
Mailing Address - Fax:
Practice Address - Street 1:1310 FOUR SEASONS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2326
Practice Address - Country:US
Practice Address - Phone:813-803-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL16000017965171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator