Provider Demographics
NPI:1245567338
Name:FOWLER, CHARLES LEE
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEE
Last Name:FOWLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1611
Mailing Address - Country:US
Mailing Address - Phone:716-870-8342
Mailing Address - Fax:716-854-2334
Practice Address - Street 1:1131 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1611
Practice Address - Country:US
Practice Address - Phone:716-870-8342
Practice Address - Fax:716-854-2334
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0747461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical