Provider Demographics
NPI:1952449472
Name:POWELL, RANDALL STUART (PSYD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:STUART
Last Name:POWELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066
Mailing Address - Country:US
Mailing Address - Phone:610-667-4652
Mailing Address - Fax:
Practice Address - Street 1:ONE BALA AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004
Practice Address - Country:US
Practice Address - Phone:610-667-4652
Practice Address - Fax:610-667-6418
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS004364L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist