Provider Demographics
NPI:1770954877
Name:FOWLER, STEPHANIE (LCPC, CADC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 N HONORE ST
Mailing Address - Street 2:SUITE 213
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4572
Mailing Address - Country:US
Mailing Address - Phone:773-669-4975
Mailing Address - Fax:844-669-3667
Practice Address - Street 1:4256 N RAVENSWOOD AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1114
Practice Address - Country:US
Practice Address - Phone:773-669-4975
Practice Address - Fax:844-669-3667
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010215101YM0800X
IL29760101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)