Basic Information
| Provider Information | |||||||||
| NPI: | 1629139464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | CEPHUS | ||||||||
| MiddleName: | RONNELL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1657 MORAGA DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945343320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075535331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 228 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945904519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075535331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 171M00000X | MCF29966 | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | MFC29966 | 01 | CA | MFT LICENSE | OTHER |