Provider Demographics
NPI:1528601663
Name:BOWLING, SHELLY R
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:R
Last Name:BOWLING
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 1:1522 BAUM ST SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-1107
Mailing Address - Country:US
Mailing Address - Phone:330-603-7073
Mailing Address - Fax:
Practice Address - Street 1:1522 BAUM ST SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-1107
Practice Address - Country:US
Practice Address - Phone:330-603-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171754101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty