Provider Demographics
NPI:1467708867
Name:FOWLER, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
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 1:1025 MOUNT MORIAH
Mailing Address - Street 2:
Mailing Address - City:TENNILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31089-3660
Mailing Address - Country:US
Mailing Address - Phone:717-495-8622
Mailing Address - Fax:
Practice Address - Street 1:1025 MOUNT MORIAH
Practice Address - Street 2:
Practice Address - City:TENNILLE
Practice Address - State:GA
Practice Address - Zip Code:31089-3660
Practice Address - Country:US
Practice Address - Phone:717-495-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
1-11-8390103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst