Healthcare Provider Details

I. General information

NPI: 1104597046
Provider Name (Legal Business Name): COWAN STEVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 GOUGLER AVE
KENT OH
44240-2401
US

IV. Provider business mailing address

PO BOX 933132
CLEVELAND OH
44193-0036
US

V. Phone/Fax

Practice location:
  • Phone: 234-788-4438
  • Fax: 330-564-9986
Mailing address:
  • Phone: 888-975-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberCHW.001604
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: