Healthcare Provider Details

I. General information

NPI: 1710800313
Provider Name (Legal Business Name): MARY ELLEN BOWERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 S COAST HWY # 2862
LAGUNA BEACH CA
92651-3681
US

IV. Provider business mailing address

5525 E PACIFIC COAST HWY APT 104
LONG BEACH CA
90804-4476
US

V. Phone/Fax

Practice location:
  • Phone: 562-444-2853
  • Fax: 562-683-0303
Mailing address:
  • Phone: 714-360-5344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: