Provider Demographics
NPI:1487942397
Name:FOWLER, MARY LU
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LU
Last Name:FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LU
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2520 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4214
Mailing Address - Country:US
Mailing Address - Phone:501-982-0528
Mailing Address - Fax:501-533-6327
Practice Address - Street 1:2520 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4214
Practice Address - Country:US
Practice Address - Phone:501-982-0528
Practice Address - Fax:501-533-6327
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8337235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist