Provider Demographics
NPI:1144970435
Name:FOWLER, BRENDA KAY
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:KAY
Other - Last Name:RUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1544 E STOCKWELL RD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-8680
Mailing Address - Country:US
Mailing Address - Phone:989-544-1213
Mailing Address - Fax:
Practice Address - Street 1:1544 E STOCKWELL RD
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-8680
Practice Address - Country:US
Practice Address - Phone:989-544-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician