Provider Demographics
NPI:1780458323
Name:BOWEN, KRISTIN (MFT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:BOWEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 S 650 W
Mailing Address - Street 2:D208
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663
Mailing Address - Country:US
Mailing Address - Phone:385-625-8589
Mailing Address - Fax:
Practice Address - Street 1:ELLIE MENTAL HEALTH
Practice Address - Street 2:3585 N UNIVERSITY AVENUE,, PROVO, UT 84604
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-797-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11334836-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty