Provider Demographics
NPI:1487069191
Name:FOWLER, DEIDRE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WESTFALL STREET
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209
Mailing Address - Country:US
Mailing Address - Phone:412-848-5784
Mailing Address - Fax:
Practice Address - Street 1:304 WESTFALL ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-9606
Practice Address - Country:US
Practice Address - Phone:412-848-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist