Provider Demographics
NPI:1760119762
Name:FOWLER, LESLIE TYREE (LMHC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:TYREE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9466 NAVARRE PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-2948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9466 NAVARRE PKWY STE B
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-2948
Practice Address - Country:US
Practice Address - Phone:850-865-5238
Practice Address - Fax:850-505-3069
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20162101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health