Healthcare Provider Details

I. General information

NPI: 1831519016
Provider Name (Legal Business Name): KEISHA POWELL PHD, CAS, ABS, ATS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KEISHA POWELL PHD, CAS, ABS, ATS

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 JESSIE LN
BROAD BROOK CT
06016-9596
US

IV. Provider business mailing address

3 JESSIE LN
BROAD BROOK CT
06016-9596
US

V. Phone/Fax

Practice location:
  • Phone: 860-983-8112
  • Fax:
Mailing address:
  • Phone: 860-983-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberC072017000387
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCAS176247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: