Healthcare Provider Details

I. General information

NPI: 1134661333
Provider Name (Legal Business Name): ELISE HELEN BOWLES MAED CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2016
Last Update Date: 11/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8717 VENICE BLVD
LOS ANGELES CA
90034-3216
US

IV. Provider business mailing address

3670 GLENDON AVE APT 314
LOS ANGELES CA
90034-6257
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7115
  • Fax:
Mailing address:
  • Phone: 562-234-3209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSPA493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: