Provider Demographics
NPI:1194793737
Name:POWELL, JOHN BRADFORD (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADFORD
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 CATON WAY SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1105
Mailing Address - Country:US
Mailing Address - Phone:360-352-4602
Mailing Address - Fax:360-352-3289
Practice Address - Street 1:2118 CATON WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-352-4602
Practice Address - Fax:360-352-3289
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2082103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2048911Medicaid