Basic Information
| Provider Information | |||||||||
| NPI: | 1609100338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 548 ASBURY NEELY WAY | ||||||||
| Address2: | |||||||||
| City: | ROEBUCK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644153206 | ||||||||
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| Practice Location | |||||||||
| Address1: | 441 LANCASTER FARM RD | ||||||||
| Address2: | ALPHABET SOUP THERAPY | ||||||||
| City: | ROEBUCK | ||||||||
| State: | NC | ||||||||
| PostalCode: | 29376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642051410 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2766 | SC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.