Provider Demographics
NPI:1750321733
Name:BOWMAN, GARY L (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:ORR
Mailing Address - State:MN
Mailing Address - Zip Code:55771-0267
Mailing Address - Country:US
Mailing Address - Phone:218-847-1676
Mailing Address - Fax:218-847-1678
Practice Address - Street 1:714 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3012
Practice Address - Country:US
Practice Address - Phone:218-847-1676
Practice Address - Fax:218-847-1678
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110240OtherUCARE MINNESOTA
MN366L4BOOtherBLUE CROSS/BLUE SHIELD
MN61-53881OtherUNITED BEHAVIORAL HEALTH
MN1011908OtherPREFERREDONE
MNHP48979OtherHELATHPARTNERS