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General NPI Number Information
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NPI Number | 1144002759
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Entity Type | Individual
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Provider Name | CHANTELLE FOWLER
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Gender | Female
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Dates
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Enumeration Date | 10/18/2023
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Last Update Date | 10/18/2023
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Provider Practice Location Address
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Address Line | 2404 RUTH HENTZ AVE BLDG B
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City | PANAMA CITY
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State | FL
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Zip | 32405-2258
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Country | US
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Telephone | 850-628-1713
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Fax | 800-308-0813
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Provider Business Mailing Address
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Address Line | 2404 RUTH HENTZ AVE BLDG B
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City | PANAMA CITY
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State | FL
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Zip | 32405-2258
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-23-303475
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License Number State |
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