Healthcare Provider Details

I. General information

NPI: 1083800262
Provider Name (Legal Business Name): NYLA P BOWENS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8712 TARA BLVD
JONESBORO GA
30236-4905
US

IV. Provider business mailing address

8712 TARA BLVD
JONESBORO GA
30236-4905
US

V. Phone/Fax

Practice location:
  • Phone: 770-478-3417
  • Fax: 770-478-3419
Mailing address:
  • Phone: 770-478-3417
  • Fax: 770-478-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC000247
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: