Provider Demographics
NPI:1790406395
Name:BOWMAN, MEKENZIE
Entity Type:Individual
Prefix:
First Name:MEKENZIE
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 27TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-6114
Mailing Address - Country:US
Mailing Address - Phone:828-371-6384
Mailing Address - Fax:
Practice Address - Street 1:8000 S LINCOLN ST STE 10
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-4201
Practice Address - Country:US
Practice Address - Phone:720-319-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician