Provider Demographics
NPI:1225690878
Name:BOWSER, CODY ASHTON RYAN
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:ASHTON RYAN
Last Name:BOWSER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:526 OLD LIVERPOOL RD STE 9
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6285
Practice Address - Country:US
Practice Address - Phone:315-453-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid