Provider Demographics
NPI:1619412285
Name:BOWERMAN, CHRISTINE ELIZABETH KANANI (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:ELIZABETH KANANI
Last Name:BOWERMAN
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 MILLER TRUNK HWY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1880
Mailing Address - Country:US
Mailing Address - Phone:218-729-6480
Mailing Address - Fax:218-729-9238
Practice Address - Street 1:1707 MILLER TRUNK HWY
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-1880
Practice Address - Country:US
Practice Address - Phone:218-729-6480
Practice Address - Fax:218-729-9238
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6088103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical