Provider Demographics
NPI:1558956540
Name:BOWERSOX, MARY KAY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAY
Last Name:BOWERSOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:BOWERSOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARY KAY SIEGEL
Mailing Address - Street 1:1001 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-8161
Mailing Address - Country:US
Mailing Address - Phone:814-274-5300
Mailing Address - Fax:
Practice Address - Street 1:1001 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:814-274-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL004637L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist