Provider Demographics
NPI:1205211083
Name:GOWAN, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GOWAN
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 1:780 CONCOURSE VLG W APT 11E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3818
Mailing Address - Country:US
Mailing Address - Phone:917-676-5958
Mailing Address - Fax:
Practice Address - Street 1:780 CONCOURSE VLG W APT 11E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3818
Practice Address - Country:US
Practice Address - Phone:917-676-5958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker