Provider Demographics
NPI:1124293113
Name:STOWELL, MARY ANNE (LCSW, PC)
Entity type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:STOWELL
Suffix:
Gender:F
Credentials:LCSW, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 SE HAWTHORNE BLVD
Mailing Address - Street 2:STE 114
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3170
Mailing Address - Country:US
Mailing Address - Phone:503-408-1759
Mailing Address - Fax:503-253-1285
Practice Address - Street 1:4511 SE HAWTHORNE BLVD
Practice Address - Street 2:STE 114
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3170
Practice Address - Country:US
Practice Address - Phone:503-408-1759
Practice Address - Fax:503-253-1285
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL29341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
115357Medicare PIN
115358Medicare PIN