Provider Demographics
NPI:1396040820
Name:BOWEN, KRISTINE MICHELLE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MICHELLE
Last Name:BOWEN
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 1:9712 S 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3051
Mailing Address - Country:US
Mailing Address - Phone:708-478-1820
Mailing Address - Fax:708-478-3316
Practice Address - Street 1:11411 W 183RD ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9450
Practice Address - Country:US
Practice Address - Phone:708-478-1820
Practice Address - Fax:708-478-1331
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932114OtherBLUE CROSS BLUE SHIEDL