Provider Demographics
NPI:1104228279
Name:BOWSER, WANDA WILSON (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:WILSON
Last Name:BOWSER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 FRANKLIN CT
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-9678
Mailing Address - Country:US
Mailing Address - Phone:270-319-7088
Mailing Address - Fax:
Practice Address - Street 1:4603 TIMBERWALK CT
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-6746
Practice Address - Country:US
Practice Address - Phone:703-864-6695
Practice Address - Fax:888-830-3233
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-20
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSLPLPA00193912235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYSLPLPA00193912Medicaid