Healthcare Provider Details

I. General information

NPI: 1750321733
Provider Name (Legal Business Name): GARY L. BOWMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 WASHINGTON AVE
DETROIT LAKES MN
56501-3012
US

IV. Provider business mailing address

PO BOX 267
ORR MN
55771-0267
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-1676
  • Fax: 218-847-1678
Mailing address:
  • Phone: 218-847-1676
  • Fax: 218-847-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP3287
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: