Provider Demographics
NPI:1518516715
Name:FOWLER, MICHELLE LYN PENFIELD (MA, LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYN PENFIELD
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 E JUANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-0344
Mailing Address - Country:US
Mailing Address - Phone:480-779-9155
Mailing Address - Fax:
Practice Address - Street 1:3048 E BASELINE RD STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7287
Practice Address - Country:US
Practice Address - Phone:480-779-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17978101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health