Provider Demographics
NPI:1619175650
Name:BOWMAN, WILFRED GORDON JR
Entity Type:Individual
Prefix:MR
First Name:WILFRED
Middle Name:GORDON
Last Name:BOWMAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:WILFRED
Other - Middle Name:GORDON
Other - Last Name:BOWMAN
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:CADC II
Mailing Address - Street 1:363 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2415
Mailing Address - Country:US
Mailing Address - Phone:805-704-0081
Mailing Address - Fax:805-489-7601
Practice Address - Street 1:363 N ELM ST
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2415
Practice Address - Country:US
Practice Address - Phone:805-704-0081
Practice Address - Fax:805-489-7601
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8510105101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)