Provider Demographics
NPI:1619378650
Name:FOWLER, SHANNON (PHD, LP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 RIVERBEND BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-2347
Mailing Address - Country:US
Mailing Address - Phone:734-474-0530
Mailing Address - Fax:
Practice Address - Street 1:741 RIVERBEND BLVD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2347
Practice Address - Country:US
Practice Address - Phone:734-474-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005172103TC0700X
MI6301016051103TC0700X
FLPY10662103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical