Basic Information
| Provider Information | |||||||||
| NPI: | 1215499785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | SHANETRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILES | ||||||||
| OtherFirstName: | SHANETRA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 896 ROBIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | LOCKHART | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786444578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123762101 | ||||||||
| FaxNumber: | 5123983040 | ||||||||
| Practice Location | |||||||||
| Address1: | 896 ROBIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | LOCKHART | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786444578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123762101 | ||||||||
| FaxNumber: | 5123983040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2019 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 63901 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.