Provider Demographics
NPI:1871610519
Name:POWELL, JAMES LEE (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 E PIEDMONT RD
Mailing Address - Street 2:SUITE 200, PMB 5
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-7752
Mailing Address - Country:US
Mailing Address - Phone:404-403-6177
Mailing Address - Fax:770-947-5650
Practice Address - Street 1:2501 E PIEDMONT RD
Practice Address - Street 2:SUITE 200, PMB 5
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-7752
Practice Address - Country:US
Practice Address - Phone:404-403-6177
Practice Address - Fax:770-947-5650
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000480686AMedicaid
GA68BBGNJMedicare ID - Type Unspecified