Provider Demographics
NPI:1639182694
Name:SOWLES, GREGORY SCOTT (HSPP LMHC PHD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:SOWLES
Suffix:
Gender:M
Credentials:HSPP LMHC PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10315 DAWSONS CREEK BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1912
Mailing Address - Country:US
Mailing Address - Phone:260-387-6340
Mailing Address - Fax:260-387-6984
Practice Address - Street 1:10315 DAWSONS CREEK BLVD STE E
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1912
Practice Address - Country:US
Practice Address - Phone:260-387-6340
Practice Address - Fax:260-387-6984
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040656103G00000X, 103TF0200X
IN39001155101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN258620OtherVISION MEDICARE GROUP NO
IN200905570AOtherMEDICAID VISION' GROUP NO.
IN200380270Medicaid
IN35-1942776Medicare UPIN
IN258620OtherVISION MEDICARE GROUP NO
IN139770AMedicare ID - Type UnspecifiedMEDICARE 'B' VISION COUNS
IN202100AMedicare ID - Type Unspecified