Healthcare Provider Details

I. General information

NPI: 1194793737
Provider Name (Legal Business Name): JOHN BRADFORD POWELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 CATON WAY SW
OLYMPIA WA
98502
US

IV. Provider business mailing address

2118 CATON WAY SW
OLYMPIA WA
98502-1105
US

V. Phone/Fax

Practice location:
  • Phone: 360-352-4602
  • Fax: 360-352-3289
Mailing address:
  • Phone: 360-352-4602
  • Fax: 360-352-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2082
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2082
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: