Provider Demographics
NPI:1598820946
Name:BOWERLY, TODD DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:DAVID
Last Name:BOWERLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 ROSEMONT RD
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E EVERGREEN BLVD
Practice Address - Street 2:SUITE 205C
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3331
Practice Address - Country:US
Practice Address - Phone:360-735-9590
Practice Address - Fax:360-735-9587
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003191103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8853394Medicare ID - Type Unspecified