Provider Demographics
NPI:1629139464
Name:FOWLER, CEPHUS RONNELL (LMFT)
Entity Type:Individual
Prefix:MR
First Name:CEPHUS
Middle Name:RONNELL
Last Name:FOWLER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 MORAGA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-3320
Mailing Address - Country:US
Mailing Address - Phone:707-553-5331
Mailing Address - Fax:
Practice Address - Street 1:228 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4519
Practice Address - Country:US
Practice Address - Phone:707-553-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMCF29966171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC29966OtherMFT LICENSE