Provider Demographics
NPI:1780633388
Name:BOWKER, SANDRA W (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:W
Last Name:BOWKER
Suffix:
Gender:F
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 LOVERS LN STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1572
Mailing Address - Country:US
Mailing Address - Phone:269-343-3010
Mailing Address - Fax:269-343-3017
Practice Address - Street 1:5148 LOVERS LN STE 2
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1572
Practice Address - Country:US
Practice Address - Phone:269-343-3010
Practice Address - Fax:269-343-3017
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010557103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C96409OtherBCBSM
MI6130541OtherPHP
MI0C96409006Medicare ID - Type Unspecified