Provider Demographics
NPI:1003169145
Name:POWELL PSYCHOLOGICAL ASSOCIATES
Entity type:Organization
Organization Name:POWELL PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-403-6177
Mailing Address - Street 1:2501 E PIEDMONT RD
Mailing Address - Street 2:SUITE 200, PMB 5
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7752
Mailing Address - Country:US
Mailing Address - Phone:404-403-6177
Mailing Address - Fax:404-393-6460
Practice Address - Street 1:2501 E PIEDMONT RD
Practice Address - Street 2:SUITE 200, PMB 5
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7752
Practice Address - Country:US
Practice Address - Phone:404-403-6177
Practice Address - Fax:404-393-6460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002212103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000480686AMedicaid
GA68BBGNJMedicare PIN