Provider Demographics
NPI:1760122733
Name:BOWEN, STEPHANIE RAE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:BOWEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8090 W 5TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-7255
Mailing Address - Country:US
Mailing Address - Phone:208-660-5958
Mailing Address - Fax:
Practice Address - Street 1:8090 W 5TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-7255
Practice Address - Country:US
Practice Address - Phone:208-660-5958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty