Provider Demographics
NPI:1285085506
Name:BOWMAN, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5832
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 FAIRCHILD ST STE 170
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-7602
Practice Address - Country:US
Practice Address - Phone:803-339-1563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid