Provider Demographics
NPI:1386697597
Name:POWELL, DAVID WAYNE (AUD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:POWELL
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12236 SLEEPY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9098
Mailing Address - Country:US
Mailing Address - Phone:773-339-4791
Mailing Address - Fax:
Practice Address - Street 1:6653 WEAVER RD STE 116
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8068
Practice Address - Country:US
Practice Address - Phone:815-315-7152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000948231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL147000948Medicaid
ILK24415Medicare ID - Type UnspecifiedMED16 753600
ILK24414Medicare ID - Type UnspecifiedMED12 560770
ILK24412Medicare ID - Type UnspecifiedMED99 560750
IL147000948Medicaid