=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508112707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA BOWMAN MA, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2012
-----------------------------------------------------
Last Update Date | 08/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 N LINDER RD STE 156-119
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-6606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-391-3160
-----------------------------------------------------
Fax | 855-745-3595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 N LINDER RD STE 156-119
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-6606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-391-3160
-----------------------------------------------------
Fax | 855-745-3595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT7109
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC 51163
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------