Provider Demographics
NPI:1972040269
Name:FOWLER, BRANDY NICOLE (MED, BCBA)
Entity Type:Individual
Prefix:MISS
First Name:BRANDY
Middle Name:NICOLE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2339 HOLDEN AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANO
Mailing Address - State:CA
Mailing Address - Zip Code:93445-9128
Mailing Address - Country:US
Mailing Address - Phone:559-313-9538
Mailing Address - Fax:
Practice Address - Street 1:2339 HOLDEN AVE
Practice Address - Street 2:
Practice Address - City:OCEANO
Practice Address - State:CA
Practice Address - Zip Code:93445-9128
Practice Address - Country:US
Practice Address - Phone:559-313-9538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11622834103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst