Provider Demographics
NPI:1871183996
Name:POWELL, TEQUAN
Entity Type:Individual
Prefix:
First Name:TEQUAN
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 DURHAM STREET EXT
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27217-8785
Mailing Address - Country:US
Mailing Address - Phone:336-684-6903
Mailing Address - Fax:
Practice Address - Street 1:2706 SAINT JUDE ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3670
Practice Address - Country:US
Practice Address - Phone:336-674-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9006488360Medicaid