Basic Information
| Provider Information | |||||||||
| NPI: | 1396184446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | KEISHA | ||||||||
| MiddleName: | LESHON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19642 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175452275 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 E MADISON ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175452275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2013 | ||||||||
| LastUpdateDate: | 06/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 036-140456 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 036.140456 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036-140456 | 01 | IL | STATE LICENSE | OTHER |