Provider Demographics
NPI:1730235631
Name:BOWIE, AUDRA (LCPC)
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:
Last Name:BOWIE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MS
Other - First Name:AUDRA
Other - Middle Name:L
Other - Last Name:BOWIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:112 E 124TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-7519
Mailing Address - Country:US
Mailing Address - Phone:773-206-5513
Mailing Address - Fax:
Practice Address - Street 1:112 E 124TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-7519
Practice Address - Country:US
Practice Address - Phone:773-206-5513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health