Provider Demographics
NPI:1376390872
Name:POWELL, ALEXANDRIA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 FELLOWS CT APT E
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3159
Mailing Address - Country:US
Mailing Address - Phone:708-657-7843
Mailing Address - Fax:
Practice Address - Street 1:400 E 22ND ST STE A
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6104
Practice Address - Country:US
Practice Address - Phone:630-919-8218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.015987225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics