Basic Information
| Provider Information | |||||||||
| NPI: | 1417475435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | GEOFFREY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20925 PROFESSIONAL PLZ STE 230 | ||||||||
| Address2: | |||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201473403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036217121 | ||||||||
| FaxNumber: | 7036657686 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 LIBERTY ST SW | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201752715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036217121 | ||||||||
| FaxNumber: | 7036657686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2017 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 0810006348 | VA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.