Healthcare Provider Details

I. General information

NPI: 1609021369
Provider Name (Legal Business Name): SANDRA BOWKER AND ASSOCIATES, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2008
Last Update Date: 11/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5930 LOVERS LN SECOND FLOOR
PORTAGE MI
49002-1673
US

IV. Provider business mailing address

5930 LOVERS LN SECOND FLOOR
PORTAGE MI
49002-1673
US

V. Phone/Fax

Practice location:
  • Phone: 269-343-3010
  • Fax: 269-343-3017
Mailing address:
  • Phone: 269-343-3010
  • Fax: 269-343-3017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEPHANIE JEAN STEWART
Title or Position: PRACTICE MANAGER
Credential: MA
Phone: 269-343-3010