Provider Demographics
NPI:1255751269
Name:FOWLER, MATTHEW (MA LPCC-S)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MA LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 FRANKFORT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1079
Mailing Address - Country:US
Mailing Address - Phone:859-753-7196
Mailing Address - Fax:859-214-4498
Practice Address - Street 1:220 FRANKFORT ST STE 1
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383
Practice Address - Country:US
Practice Address - Phone:859-753-7196
Practice Address - Fax:859-214-4498
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCPCC00225355101YP2500X
KY164566101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherTAX ID