Provider Demographics
NPI:1558509299
Name:BOWLES, KIMBERLY B (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:BOWLES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MYSTIC AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4632
Mailing Address - Country:US
Mailing Address - Phone:678-139-6119
Mailing Address - Fax:781-396-1439
Practice Address - Street 1:45 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1208
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-541-8472
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1161391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical