Provider Demographics
NPI:1063195311
Name:POWELL, LHEADRY DWAYNE
Entity type:Individual
Prefix:
First Name:LHEADRY
Middle Name:DWAYNE
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1325
Mailing Address - Country:US
Mailing Address - Phone:909-543-9122
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4969
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-08-28
Deactivation Date:2023-08-11
Deactivation Code:
Reactivation Date:2023-08-28
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician