Provider Demographics
NPI:1215038880
Name:POWELL, ERIC C (PSYD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:POWELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 JENKINS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-9483
Mailing Address - Country:US
Mailing Address - Phone:970-247-2035
Mailing Address - Fax:
Practice Address - Street 1:2855 MAIN AVE STE A105
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5959
Practice Address - Country:US
Practice Address - Phone:970-382-6690
Practice Address - Fax:970-382-0207
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY2927103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPSY2927OtherST LICENSE