Provider Demographics
NPI:1881830586
Name:POWELL, DEBORAH G (NCTMB)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:G
Last Name:POWELL
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9448D W FAIRVIEW AVE # D
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8101
Mailing Address - Country:US
Mailing Address - Phone:208-629-2006
Mailing Address - Fax:
Practice Address - Street 1:9448D W FAIRVIEW AVE # D
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8101
Practice Address - Country:US
Practice Address - Phone:208-629-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID511654-06OtherNATIONAL CERTIFICATION BOARD FOR THERAPEUTIC MASSAGE & BODYWORK
IDMX 070017OtherBOISE CITY MASSAGE EXEMPT LICENSE