Provider Demographics
NPI:1225677040
Name:GOWANS, NATALIE MELISSA
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:MELISSA
Last Name:GOWANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:MELISSA
Other - Last Name:BLASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3132 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4421
Mailing Address - Country:US
Mailing Address - Phone:619-683-3100
Mailing Address - Fax:
Practice Address - Street 1:3132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4421
Practice Address - Country:US
Practice Address - Phone:619-683-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3578073106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician