Provider Demographics
NPI:1881944049
Name:FOWLER, ALISA GAIL
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:GAIL
Last Name:FOWLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 E BURNSIDE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1768
Mailing Address - Country:US
Mailing Address - Phone:503-208-5755
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST STE 206
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1768
Practice Address - Country:US
Practice Address - Phone:503-208-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR80031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical