Provider Demographics
NPI:1104597046
Name:STEVENS, COWAN
Entity type:Individual
Prefix:
First Name:COWAN
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933132
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0036
Mailing Address - Country:US
Mailing Address - Phone:888-975-9188
Mailing Address - Fax:
Practice Address - Street 1:143 GOUGLER AVE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-2401
Practice Address - Country:US
Practice Address - Phone:234-788-4438
Practice Address - Fax:330-564-9986
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCHW.001604172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker