Provider Demographics
NPI:1629784764
Name:BOWEN, BURCH MICHAEL II (LAC)
Entity Type:Individual
Prefix:
First Name:BURCH
Middle Name:MICHAEL
Last Name:BOWEN
Suffix:II
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 SPRUCE RD APT 11
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3393
Mailing Address - Country:US
Mailing Address - Phone:406-250-1655
Mailing Address - Fax:
Practice Address - Street 1:2282 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-8499
Practice Address - Country:US
Practice Address - Phone:406-885-8851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-PRV-62259101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty