Provider Demographics
NPI:1629296033
Name:BOWEN, MELISSA ROSS (MS, MDIV)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROSS
Last Name:BOWEN
Suffix:
Gender:F
Credentials:MS, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 S LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-5724
Mailing Address - Country:US
Mailing Address - Phone:870-743-6881
Mailing Address - Fax:
Practice Address - Street 1:5 REMINGTON CV
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8274
Practice Address - Country:US
Practice Address - Phone:501-850-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1325225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134141721Medicaid