Provider Demographics
NPI:1285031435
Name:BOWEN, LISA RAE (CMP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:RAE
Last Name:BOWEN
Suffix:
Gender:F
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 CENTER BLVD # 127
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1764
Mailing Address - Country:US
Mailing Address - Phone:415-454-3400
Mailing Address - Fax:
Practice Address - Street 1:12 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2009
Practice Address - Country:US
Practice Address - Phone:415-454-3400
Practice Address - Fax:415-532-1879
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
CACAMTC 32577225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32577OtherCAMTC