Healthcare Provider Details

I. General information

NPI: 1386764728
Provider Name (Legal Business Name): MARGARET SUZANNE FOWLER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARGARET SUZANNE RUYAK MS

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 SHINKLE RD
TULAROSA NM
88352-9522
US

IV. Provider business mailing address

869 16-SPRINGS CANYON ROAD
CLOUDCROFT NM
88317
US

V. Phone/Fax

Practice location:
  • Phone: 575-491-3711
  • Fax:
Mailing address:
  • Phone: 575-491-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173F00000X
TaxonomySleep Specialist (PhD)
License Number1175
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1175
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier24132268
Identifier TypeMEDICAID
Identifier StateNM
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: