Provider Demographics
NPI:1386302644
Name:BOWEN, MALLORY M (COUNSELOR)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:M
Last Name:BOWEN
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:MS
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 E 860 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5013
Mailing Address - Country:US
Mailing Address - Phone:801-420-3117
Mailing Address - Fax:
Practice Address - Street 1:208 E 860 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5013
Practice Address - Country:US
Practice Address - Phone:801-420-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty