Healthcare Provider Details

I. General information

NPI: 1215283833
Provider Name (Legal Business Name): GEORGE MARSHALL COWAN III PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CARPENTER RD RADER US ARMY HEALTH CLINIC
FT MYER VA
22211-1009
US

IV. Provider business mailing address

401 CARPENTER RD RADER US ARMY HEALTH CLINIC
FT MYER VA
22211-1009
US

V. Phone/Fax

Practice location:
  • Phone: 703-696-3656
  • Fax:
Mailing address:
  • Phone: 703-696-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04056
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004541
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: