Provider Demographics
NPI:1407810492
Name:FOWLER, MICHELLE B (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6692 PEARL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7209
Mailing Address - Country:US
Mailing Address - Phone:415-208-1127
Mailing Address - Fax:
Practice Address - Street 1:6358 EDGEMERE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3517
Practice Address - Country:US
Practice Address - Phone:915-562-8525
Practice Address - Fax:915-566-3889
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1180840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAB15898OtherMEDICARE ID - TYPE UNSPECIFIED