Provider Demographics
NPI:1053018671
Name:FOWLER, DRAYTON K
Entity type:Individual
Prefix:
First Name:DRAYTON
Middle Name:K
Last Name:FOWLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 LYNWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-1569
Mailing Address - Country:US
Mailing Address - Phone:559-361-8753
Mailing Address - Fax:
Practice Address - Street 1:11344 COLOMA RD STE 570
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-6304
Practice Address - Country:US
Practice Address - Phone:916-676-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3293182106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician