Provider Demographics
NPI:1952712838
Name:FOWLER, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
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 1:750 S OBT TRL STE 111
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-3154
Mailing Address - Country:US
Mailing Address - Phone:407-415-5982
Mailing Address - Fax:407-884-7775
Practice Address - Street 1:750 S OBT TRL STE 111
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-3154
Practice Address - Country:US
Practice Address - Phone:407-415-5982
Practice Address - Fax:407-884-7775
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health