Provider Demographics
NPI:1720746654
Name:LADER, BOWEN (LCMHCA)
Entity type:Individual
Prefix:
First Name:BOWEN
Middle Name:
Last Name:LADER
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2582
Mailing Address - Country:US
Mailing Address - Phone:336-939-5553
Mailing Address - Fax:336-546-7630
Practice Address - Street 1:942 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2582
Practice Address - Country:US
Practice Address - Phone:336-939-5553
Practice Address - Fax:336-546-7630
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCA19135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA