Provider Demographics
NPI:1255602470
Name:FOWLER, MARIE ANTOINETTE (LCSW)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14040 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2415
Mailing Address - Country:US
Mailing Address - Phone:760-241-3744
Mailing Address - Fax:760-843-1084
Practice Address - Street 1:15000 7TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3852
Practice Address - Country:US
Practice Address - Phone:760-490-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA239051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical