MEDICARE: POWERS PSYCHOLOGICAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	20040449A	IN

General Provider Information

NPI Number	:	1912121070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWERS PSYCHOLOGICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	10311 DAWSONS CREEK BLVD
Second Line	:	SUITE F
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1913
Country	:	US
Telephone Number	:	260-490-5800
Fax Number	:	260-490-8722

Provider Business Practice Location Address
First Line	:	10311 DAWSONS CREEK BLVD
Second Line	:	SUITE F
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1913
Country	:	US
Telephone Number	:	260-490-5800
Fax Number	:	260-490-8722

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. ABIGAIL DORMIRE POWERS
Credential	:	PH.D.
Telephone Number	:	260-490-5800

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	08/22/2020

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