Healthcare Provider Details

I. General information

NPI: 1194540831
Provider Name (Legal Business Name): TRISTAN GAGE BOWEN LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 ELK RIVER RD
ELKVIEW WV
25701
US

IV. Provider business mailing address

5004 ELK RIVER RD
ELKVIEW WV
25701
US

V. Phone/Fax

Practice location:
  • Phone: 304-759-9835
  • Fax:
Mailing address:
  • Phone: 304-759-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBP00947009
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: