Provider Demographics
NPI:1033092614
Name:BOWLINE, LISA A (CASAC A)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BOWLINE
Suffix:
Gender:F
Credentials:CASAC A
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:329 N SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1755
Mailing Address - Country:US
Mailing Address - Phone:315-471-1564
Mailing Address - Fax:315-471-2431
Practice Address - Street 1:133 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2027
Practice Address - Country:US
Practice Address - Phone:315-382-3334
Practice Address - Fax:315-382-3334
Is Sole Proprietor?:No
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35025103TA0400X
35025101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)