Provider Demographics
NPI:1811693674
Name:FOWLER, SIMON CHARLES (PTA)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:CHARLES
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3393 ORANGE LN NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6372
Mailing Address - Country:US
Mailing Address - Phone:404-600-7684
Mailing Address - Fax:
Practice Address - Street 1:1615 RIDENOUR BLVD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4463
Practice Address - Country:US
Practice Address - Phone:770-580-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA005007225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty