Provider Demographics
NPI:1700395464
Name:FOWLER, PATRICK JAMES
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:JAMES
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 1:615 E NORTH BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4133
Mailing Address - Country:US
Mailing Address - Phone:614-593-2649
Mailing Address - Fax:
Practice Address - Street 1:615 E NORTH BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4133
Practice Address - Country:US
Practice Address - Phone:614-593-2649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2002181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty