Provider Demographics
NPI:1639106982
Name:BOWSHER, KIMBERLEY JO (LCSW, ACSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLEY
Middle Name:JO
Last Name:BOWSHER
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:MRS
Other - First Name:KIMBERLEY
Other - Middle Name:JO
Other - Last Name:HAZLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1015 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1526
Mailing Address - Country:US
Mailing Address - Phone:574-722-5151
Mailing Address - Fax:574-739-1414
Practice Address - Street 1:401 E 8TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-1443
Practice Address - Country:US
Practice Address - Phone:574-223-8565
Practice Address - Fax:574-223-8786
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000998A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN338948OtherVALUE OPTIONS
IN133203000OtherMAGELLAN BEHAVIORAL
INANTHEMOther000000184278
INP0016004Medicare ID - Type UnspecifiedMEDICARE RAILROAD