Healthcare Provider Details

I. General information

NPI: 1043780596
Provider Name (Legal Business Name): BRENDA LYNN FOWLER-LONGORIA PEER COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4238 AUBURN WAY N
AUBURN WA
98002-1311
US

IV. Provider business mailing address

4238 AUBURN WAY N
AUBURN WA
98002-1311
US

V. Phone/Fax

Practice location:
  • Phone: 253-876-7600
  • Fax:
Mailing address:
  • Phone: 206-423-9547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60445005
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: