Provider Demographics
NPI:1336149699
Name:ROWLETT, RICHARD (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ROWLETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44061-0660
Mailing Address - Country:US
Mailing Address - Phone:440-390-8903
Mailing Address - Fax:
Practice Address - Street 1:4350 SIR ROBERT AVE
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4139
Practice Address - Country:US
Practice Address - Phone:440-390-8903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.5557103T00000X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2206071Medicaid
OH000000296011OtherANTHEM BLUE SHIELD
OH432021960RROtherSUMMACARE
OHCP24192Medicare PIN
OH432021960RROtherSUMMACARE
OHP00047657Medicare PIN