Healthcare Provider Details

I. General information

NPI: 1790953552
Provider Name (Legal Business Name): ANGELA MARIE FOWLER LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5031 PARK LAKE RD MEDIDIAN PROFESSIONAL PSYCHOLOGICAL CONSULTANTS
EAST LANSING MI
48823
US

IV. Provider business mailing address

2310 LOCKWOODE CT
HOLT MI
48842
US

V. Phone/Fax

Practice location:
  • Phone: 517-332-0811
  • Fax: 517-332-4452
Mailing address:
  • Phone: 517-694-0257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: