Provider Demographics
NPI:1114210564
Name:FOWLER, STEPHANIA MARICE
Entity Type:Individual
Prefix:
First Name:STEPHANIA
Middle Name:MARICE
Last Name:FOWLER
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 1:356 E BOLLING AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5606
Mailing Address - Country:US
Mailing Address - Phone:501-666-8686
Mailing Address - Fax:
Practice Address - Street 1:6450 WEST 12TH
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204
Practice Address - Country:US
Practice Address - Phone:501-666-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health