Provider Demographics
NPI:1053097923
Name:FOWLER, BLAKE ANTHONY (APC, NCC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANTHONY
Last Name:FOWLER
Suffix:
Gender:M
Credentials:APC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 OSPREY POINT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087
Mailing Address - Country:US
Mailing Address - Phone:470-286-5985
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNET DRIVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:678-209-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009118101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor