Provider Demographics
NPI:1760833164
Name:BOWERS, DEREK SHEA (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:SHEA
Last Name:BOWERS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N BOONE ST STE 13
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5659
Mailing Address - Country:US
Mailing Address - Phone:865-338-5384
Mailing Address - Fax:865-338-5383
Practice Address - Street 1:207 N BOONE ST STE 13
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5659
Practice Address - Country:US
Practice Address - Phone:423-218-2217
Practice Address - Fax:865-338-5383
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN71191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ053172Medicaid