Healthcare Provider Details

I. General information

NPI: 1326662685
Provider Name (Legal Business Name): ERIC DAVID POWELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 GARDENDALE ST STE 502
SAN ANTONIO TX
78229-3699
US

IV. Provider business mailing address

4230 GARDENDALE ST STE 502
SAN ANTONIO TX
78229-3699
US

V. Phone/Fax

Practice location:
  • Phone: 314-540-6067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number37727
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: