Provider Demographics
NPI:1386150738
Name:BOWMAN, KRYSTOFFER LOREN (LPC)
Entity type:Individual
Prefix:MR
First Name:KRYSTOFFER
Middle Name:LOREN
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:KRYSTOFFER
Other - Middle Name:LOREN
Other - Last Name:GAETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:915 PINON RANCH VW
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3578
Mailing Address - Country:US
Mailing Address - Phone:719-357-7889
Mailing Address - Fax:719-213-2484
Practice Address - Street 1:915 PINON RANCH VW
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3578
Practice Address - Country:US
Practice Address - Phone:719-357-7889
Practice Address - Fax:719-213-2484
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015508101YM0800X
COLPC.0015508101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83-4491444Medicaid