Provider Demographics
NPI:1851660385
Name:POWELL, GREGORY JAVON (BHRS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAVON
Last Name:POWELL
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CROSSWINDS DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-7502
Mailing Address - Country:US
Mailing Address - Phone:919-438-9125
Mailing Address - Fax:
Practice Address - Street 1:206 CROSSWINDS DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-7502
Practice Address - Country:US
Practice Address - Phone:919-438-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation