Provider Demographics
NPI:1871253021
Name:BOWLES, MICHELLE LYNN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:BOWLES
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 1:2080 S E ST STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2706
Mailing Address - Country:US
Mailing Address - Phone:909-900-5856
Mailing Address - Fax:
Practice Address - Street 1:2080 S E ST STE 250
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2706
Practice Address - Country:US
Practice Address - Phone:909-900-5856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1449931121101YA0400X
390200000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program