Provider Demographics
NPI:1659686905
Name:FOWLER, TERRY A (LMFT, RD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LMFT, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 CANYON CREST DR STE 103
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6353
Mailing Address - Country:US
Mailing Address - Phone:909-319-7147
Mailing Address - Fax:
Practice Address - Street 1:5225 CANYON CREST DR STE 103
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6353
Practice Address - Country:US
Practice Address - Phone:909-319-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA001010567133V00000X
CA105801106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered