Provider Demographics
NPI:1477185437
Name:POWELL, ISABELLA TERI (LMT)
Entity type:Individual
Prefix:
First Name:ISABELLA
Middle Name:TERI
Last Name:POWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12715 N. 10TH AVE.
Mailing Address - Street 2:
Mailing Address - City:HIDDEN SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83714
Mailing Address - Country:US
Mailing Address - Phone:208-994-9831
Mailing Address - Fax:
Practice Address - Street 1:12715 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:HIDDEN SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83714-9333
Practice Address - Country:US
Practice Address - Phone:208-994-9831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-2140225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist