Provider Demographics
NPI:1639114747
Name:GOWEN, BARTLETT L (COTA)
Entity Type:Individual
Prefix:
First Name:BARTLETT
Middle Name:L
Last Name:GOWEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 RANDOLPH PL E
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-4426
Mailing Address - Country:US
Mailing Address - Phone:434-845-8765
Mailing Address - Fax:
Practice Address - Street 1:1912 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1708
Practice Address - Country:US
Practice Address - Phone:434-845-8765
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192596OtherANTHEM
VA496612Medicare ID - Type Unspecified