Provider Demographics
NPI:1275916694
Name:FOWLER, TYRA
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:
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 1:2705 DEER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75040-3939
Mailing Address - Country:US
Mailing Address - Phone:972-898-1630
Mailing Address - Fax:
Practice Address - Street 1:2705 DEER CREEK CT
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3939
Practice Address - Country:US
Practice Address - Phone:972-898-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11623101YA0400X
TX68725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)