Provider Demographics
NPI:1609100338
Name:FOWLER, LISA MARIE (MSP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 ASBURY NEELY WAY
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376
Mailing Address - Country:US
Mailing Address - Phone:864-415-3206
Mailing Address - Fax:
Practice Address - Street 1:441 LANCASTER FARM RD
Practice Address - Street 2:ALPHABET SOUP THERAPY
Practice Address - City:ROEBUCK
Practice Address - State:NC
Practice Address - Zip Code:29376
Practice Address - Country:US
Practice Address - Phone:864-205-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2766235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist