=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487390084
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRICK A POWELL LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2022
-----------------------------------------------------
Last Update Date | 05/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 586 S ROSEHALL LN
-----------------------------------------------------
City | ROUND LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60073-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-505-6944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 586 S ROSEHALL LN
-----------------------------------------------------
City | ROUND LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60073-4268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-505-6944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227022514
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227.022514
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------