Provider Demographics
NPI:1386764728
Name:FOWLER, MARGARET SUZANNE (PHD)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:SUZANNE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:SUZANNE
Other - Last Name:RUYAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:869 16-SPRINGS CANYON ROAD
Mailing Address - Street 2:
Mailing Address - City:CLOUDCROFT
Mailing Address - State:NM
Mailing Address - Zip Code:88317
Mailing Address - Country:US
Mailing Address - Phone:575-491-3711
Mailing Address - Fax:
Practice Address - Street 1:47 SHINKLE RD
Practice Address - Street 2:
Practice Address - City:TULAROSA
Practice Address - State:NM
Practice Address - Zip Code:88352-9522
Practice Address - Country:US
Practice Address - Phone:575-491-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1175173F00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173F00000XOther Service ProvidersSleep Specialist, PhD
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24132268Medicaid