Provider Demographics
NPI:1548806375
Name:FOWLER, MELINDA MICHELLE (LCSW, CCTP)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:MICHELLE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LCSW, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5341
Mailing Address - Country:US
Mailing Address - Phone:575-405-7323
Mailing Address - Fax:
Practice Address - Street 1:1350 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5341
Practice Address - Country:US
Practice Address - Phone:575-405-7323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2024-01661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical