Basic Information
Provider Information | |||||||||
NPI: | 1992832547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWLES | ||||||||
FirstName: | ZETTA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY. D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NICELY | ||||||||
OtherFirstName: | ZETTA | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PSY.D | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 140 CHRISTIANSBURG PIKE NE | ||||||||
Address2: |   | ||||||||
City: | FLOYD | ||||||||
State: | VA | ||||||||
PostalCode: | 240913742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407459290 | ||||||||
FaxNumber: | 2763983331 | ||||||||
Practice Location | |||||||||
Address1: | 140 CHRISTIANSBURG PIKE NE | ||||||||
Address2: |   | ||||||||
City: | FLOYD | ||||||||
State: | VA | ||||||||
PostalCode: | 240913742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407459290 | ||||||||
FaxNumber: | 2763983331 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2007 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 0810004791 | VA | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.