Provider Demographics
NPI:1447611066
Name:FOWLER, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
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 1:311 13TH AVE E APT 6
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-6103
Mailing Address - Country:US
Mailing Address - Phone:646-853-3970
Mailing Address - Fax:
Practice Address - Street 1:3330 MONTE VILLA PKWY
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-8972
Practice Address - Country:US
Practice Address - Phone:425-408-7733
Practice Address - Fax:425-408-7740
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60680511103T00000X
WA510336A103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist