=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295900579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT BLYTHE BOWDEN L. C. P. C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2008
-----------------------------------------------------
Last Update Date | 01/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2909 CHURCHVILLE RD
-----------------------------------------------------
City | CHURCHVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21028-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-734-6439
-----------------------------------------------------
Fax | 410-734-6123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5622 CRESCENT RIDGE DR
-----------------------------------------------------
City | WHITE MARSH
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21162-1149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-830-9268
-----------------------------------------------------
Fax | 410-734-6123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LC2595
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------