Healthcare Provider Details

I. General information

NPI: 1629139464
Provider Name (Legal Business Name): CEPHUS RONNELL FOWLER LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 BROADWAY ST
VALLEJO CA
94590-4519
US

IV. Provider business mailing address

1657 MORAGA DR
FAIRFIELD CA
94534-3320
US

V. Phone/Fax

Practice location:
  • Phone: 707-553-5331
  • Fax:
Mailing address:
  • Phone: 707-553-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberMCF29966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: