Provider Demographics
NPI:1952495020
Name:POWELL, JOHN LEE III (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEE
Last Name:POWELL
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 LONETREE BLVD
Mailing Address - Street 2:STE. 216
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3772
Mailing Address - Country:US
Mailing Address - Phone:916-342-4077
Mailing Address - Fax:
Practice Address - Street 1:5701 LONETREE BLVD
Practice Address - Street 2:STE. 216
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3772
Practice Address - Country:US
Practice Address - Phone:916-342-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23682103TB0200X, 103TF0000X, 103TM1800X, 103TC2200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical