Provider Demographics
NPI:1114493467
Name:BOWMAN, LARRISSA
Entity Type:Individual
Prefix:
First Name:LARRISSA
Middle Name:
Last Name:BOWMAN
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 1:1936 CAMBRIDGE CT APT 4B
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-1430
Mailing Address - Country:US
Mailing Address - Phone:224-387-9775
Mailing Address - Fax:
Practice Address - Street 1:1936 CAMBRIDGE CT APT 4B
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-1430
Practice Address - Country:US
Practice Address - Phone:224-387-9775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician