Provider Demographics
NPI:1073671715
Name:FOWLER, JOHN R (LISW-CP, CADC-III)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:FOWLER
Suffix:
Gender:M
Credentials:LISW-CP, CADC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 30819
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-0014
Mailing Address - Country:US
Mailing Address - Phone:843-248-9216
Mailing Address - Fax:843-248-4013
Practice Address - Street 1:203 BEATY STREET
Practice Address - Street 2:
Practice Address - City:COWNAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-248-9216
Practice Address - Fax:843-248-4013
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI721101YA0400X
SC23071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ27145Medicare UPIN
SCQ271450281Medicare PIN