Provider Demographics
NPI:1477709392
Name:FOWLER PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:FOWLER PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-545-8833
Mailing Address - Street 1:5353 GAMBLE DR
Mailing Address - Street 2:108
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1509
Mailing Address - Country:US
Mailing Address - Phone:952-545-8833
Mailing Address - Fax:952-224-2299
Practice Address - Street 1:5353 GAMBLE DR
Practice Address - Street 2:108
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1509
Practice Address - Country:US
Practice Address - Phone:952-545-8833
Practice Address - Fax:952-224-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1765251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN620000219OtherMEDICARE