Provider Demographics
NPI:1134885916
Name:FOWLER, TAYLOR MARIE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2842
Mailing Address - Country:US
Mailing Address - Phone:352-314-3760
Mailing Address - Fax:352-314-2909
Practice Address - Street 1:1650 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2842
Practice Address - Country:US
Practice Address - Phone:352-314-3760
Practice Address - Fax:352-314-2909
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-189665106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty