Healthcare Provider Details

I. General information

NPI: 1467096420
Provider Name (Legal Business Name): STEPHANIE BOWER LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2019
Last Update Date: 11/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E WINTER AVE
DANVILLE IL
61832-2295
US

IV. Provider business mailing address

27293 POTOMAC COLLISON RD
POTOMAC IL
61865-3143
US

V. Phone/Fax

Practice location:
  • Phone: 217-651-6801
  • Fax: 217-651-6802
Mailing address:
  • Phone: 217-776-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150104020
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: