Provider Demographics
NPI:1093977100
Name:BOWN, MARJORIE LIZA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:LIZA
Last Name:BOWN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3064
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1164
Mailing Address - Country:US
Mailing Address - Phone:909-896-2433
Mailing Address - Fax:909-284-4111
Practice Address - Street 1:225 W HOSPITALITY LN
Practice Address - Street 2:SUITE 208A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3237
Practice Address - Country:US
Practice Address - Phone:909-896-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA290361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health