Provider Demographics
NPI:1851647168
Name:FOWLER, KYMRY HART (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KYMRY
Middle Name:HART
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:127 AVENIDA SERRA APT B
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-6780
Mailing Address - Country:US
Mailing Address - Phone:949-374-4868
Mailing Address - Fax:949-606-8262
Practice Address - Street 1:27184 ORTEGA HWY STE 103
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2796
Practice Address - Country:US
Practice Address - Phone:949-374-4868
Practice Address - Fax:949-606-8262
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17425235Z00000X
CASP17425235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP17425OtherCALIFORNIA SPEECH LANGUAGE PATHOLOGIST LICENSE