Provider Demographics
NPI:1184869182
Name:POWELL, RONALD ELLIS
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:ELLIS
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RON
Other - Middle Name:ELLIS
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5965 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1720
Mailing Address - Country:US
Mailing Address - Phone:801-263-7100
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:800-322-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6220020-3503101YM0800X
UT111182-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health