Healthcare Provider Details

I. General information

NPI: 1417475435
Provider Name (Legal Business Name): GEOFFREY FOWLER PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 10/14/2023
Certification Date: 10/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 LIBERTY ST SW
LEESBURG VA
20175-2715
US

IV. Provider business mailing address

9202 CENTER OAK CT
MECHANICSVILLE VA
23116-2744
US

V. Phone/Fax

Practice location:
  • Phone: 703-621-7121
  • Fax: 703-665-7686
Mailing address:
  • Phone: 804-207-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810006348
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: