Provider Demographics
NPI:1073660551
Name:POWELL, JOHN W (PHD, ATC)
Entity type:Individual
Prefix:PROF
First Name:JOHN
Middle Name:W
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 PLEASANT RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-9707
Mailing Address - Country:US
Mailing Address - Phone:517-646-6310
Mailing Address - Fax:
Practice Address - Street 1:105 IM CIRCLE
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1020
Practice Address - Country:US
Practice Address - Phone:517-432-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer