Provider Demographics
NPI:1396966958
Name:POWELL, SUSAN (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
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:P.O. BOX 2811
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98231
Mailing Address - Country:US
Mailing Address - Phone:618-920-2663
Mailing Address - Fax:
Practice Address - Street 1:4972 BENCHMARK CENTRE
Practice Address - Street 2:SUITE 200
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-920-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232031OtherBLUE CROSS & BLUE SHIELD