Healthcare Provider Details

I. General information

NPI: 1205325917
Provider Name (Legal Business Name): NICOLE BOWKER LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NE LOOP 410 STE D200
SAN ANTONIO TX
78209-1407
US

IV. Provider business mailing address

7855 KITTY HAWK RD APT 1304
CONVERSE TX
78109-1772
US

V. Phone/Fax

Practice location:
  • Phone: 210-822-2600
  • Fax:
Mailing address:
  • Phone: 630-701-5154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17813869
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: