Healthcare Provider Details

I. General information

NPI: 1023004884
Provider Name (Legal Business Name): CAROL RENE FOWLER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SERE DET, 1-145TH AVN REGT BLDG 750, 3RD AVE
FORT RUCKER AL
32326
US

IV. Provider business mailing address

302 WASHINGTON AVE
ENTERPRISE AL
36330-4411
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-0441
  • Fax:
Mailing address:
  • Phone: 334-406-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1277
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: