Healthcare Provider Details

I. General information

NPI: 1285031435
Provider Name (Legal Business Name): LISA RAE BOWEN CMT, NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 LAS GALLINAS AVE # 2023
SAN RAFAEL CA
94903-3618
US

IV. Provider business mailing address

454 LAS GALLINAS AVE # 2023
SAN RAFAEL CA
94903-3618
US

V. Phone/Fax

Practice location:
  • Phone: 415-454-3400
  • Fax:
Mailing address:
  • Phone: 415-454-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberCAMTC 32577
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberNBHWCA3622179
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: