Provider Demographics
NPI:1154155919
Name:ROWAN, MARY LOIS
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOIS
Last Name:ROWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 GEIGER DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9304
Mailing Address - Country:US
Mailing Address - Phone:386-795-9354
Mailing Address - Fax:
Practice Address - Street 1:454 FORT FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-9714
Practice Address - Country:US
Practice Address - Phone:386-562-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-366779106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician