Provider Demographics
NPI:1710453998
Name:KELLY JO BOWLES PLLC
Entity Type:Organization
Organization Name:KELLY JO BOWLES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-324-6242
Mailing Address - Street 1:2578 ENTERPRISE RD # 171
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7904
Mailing Address - Country:US
Mailing Address - Phone:386-385-4748
Mailing Address - Fax:
Practice Address - Street 1:104 TREEMONTE DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7953
Practice Address - Country:US
Practice Address - Phone:386-385-4748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty