Provider Demographics
NPI:1386984672
Name:POWELL, KEVIN DANIEL (PTA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DANIEL
Last Name:POWELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TRAIL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:IN
Mailing Address - Zip Code:46701-1541
Mailing Address - Country:US
Mailing Address - Phone:260-636-1000
Mailing Address - Fax:260-636-7954
Practice Address - Street 1:250 SPRING BEACH ROAD
Practice Address - Street 2:
Practice Address - City:ROME CITY
Practice Address - State:IN
Practice Address - Zip Code:46784-9703
Practice Address - Country:US
Practice Address - Phone:309-236-8531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004581A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant