Provider Demographics
NPI:1831519016
Name:POWELL, KEISHA (PHD, CAS, ABS, ATS)
Entity type:Individual
Prefix:DR
First Name:KEISHA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:PHD, CAS, ABS, ATS
Other - Prefix:DR
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, CAS, ABS, ATS
Mailing Address - Street 1:3 JESSIE LN
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9596
Mailing Address - Country:US
Mailing Address - Phone:860-983-8112
Mailing Address - Fax:
Practice Address - Street 1:3 JESSIE LN
Practice Address - Street 2:
Practice Address - City:BROAD BROOK
Practice Address - State:CT
Practice Address - Zip Code:06016-9596
Practice Address - Country:US
Practice Address - Phone:860-983-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC072017000387103K00000X
FLCAS176247174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0080-96340Medicaid
FL23907OtherBOARD CERTIFIED SEXOLOGIST
FLCAS176247OtherCERTIFIED AUTISM SPECIALIST
CTC072017000387OtherSPECIAL EDUCATION-AUTISM