Provider Demographics
NPI:1932533296
Name:POWELL, GARY RAYMOND (DMIN, LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RAYMOND
Last Name:POWELL
Suffix:
Gender:M
Credentials:DMIN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9704
Mailing Address - Country:US
Mailing Address - Phone:706-305-3137
Mailing Address - Fax:706-305-3139
Practice Address - Street 1:600 MARTINTOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-2011
Practice Address - Country:US
Practice Address - Phone:803-599-1506
Practice Address - Fax:706-305-3139
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional