Healthcare Provider Details

I. General information

NPI: 1629248877
Provider Name (Legal Business Name): SANDY A BOWERSOX PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WASHINGTON AVE STE 100
EVANSVILLE IN
47714-0550
US

IV. Provider business mailing address

3900 WASHINGTON AVE # 100
EVANSVILLE IN
47714-0550
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-6694
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042330A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20042330A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: