Provider Demographics
NPI:1780474791
Name:POWELL, STORMY
Entity type:Individual
Prefix:
First Name:STORMY
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CONNIE LN
Mailing Address - Street 2:
Mailing Address - City:WASKOM
Mailing Address - State:TX
Mailing Address - Zip Code:75692-4825
Mailing Address - Country:US
Mailing Address - Phone:903-926-5267
Mailing Address - Fax:
Practice Address - Street 1:1001 W SW LOOP 323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9416
Practice Address - Country:US
Practice Address - Phone:430-205-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician