Healthcare Provider Details

I. General information

NPI: 1629557905
Provider Name (Legal Business Name): LEA KATHRYN BOWMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARK BLVD
BOISE ID
83712-7791
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4100
  • Fax:
Mailing address:
  • Phone: 208-381-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-36211
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: