Provider Demographics
NPI:1841408127
Name:FOWLER, BROCK L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:L
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-5836
Mailing Address - Country:US
Mailing Address - Phone:336-327-1496
Mailing Address - Fax:
Practice Address - Street 1:1560 E CHEVY CHASE DR STE 130
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4140
Practice Address - Country:US
Practice Address - Phone:336-327-1496
Practice Address - Fax:415-296-5299
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20528103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical