Provider Demographics
NPI:1972851632
Name:POWELL, CHAD ALVA (DPT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ALVA
Last Name:POWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361-2008
Mailing Address - Country:US
Mailing Address - Phone:573-253-1633
Mailing Address - Fax:
Practice Address - Street 1:2064 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1592
Practice Address - Country:US
Practice Address - Phone:573-486-1600
Practice Address - Fax:573-486-1605
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist