Provider Demographics
NPI:1215965843
Name:POWELL, DIANE MARIE (PH D)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 N BURNHAM HWY
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2803
Mailing Address - Country:US
Mailing Address - Phone:860-376-0659
Mailing Address - Fax:860-376-6478
Practice Address - Street 1:12 CASE ST
Practice Address - Street 2:SUITE 310
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2222
Practice Address - Country:US
Practice Address - Phone:860-887-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001592CT103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical