Provider Demographics
NPI:1770806499
Name:BOWMAN, PHYLLIS IRENE (MSW, LISW-S)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:IRENE
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:IRENE
Other - Last Name:TADEWALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3330 W 4000 S APT H105
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-9547
Mailing Address - Country:US
Mailing Address - Phone:513-551-7664
Mailing Address - Fax:
Practice Address - Street 1:3330 W 4000 S APT H105
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-9547
Practice Address - Country:US
Practice Address - Phone:513-551-7664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12013001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12639231OtherCAQH
OH0155000Medicaid