Provider Demographics
NPI:1881738276
Name:FOWLER, SUSAN H (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:H
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PSYD
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 511
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-0511
Mailing Address - Country:US
Mailing Address - Phone:231-796-3339
Mailing Address - Fax:
Practice Address - Street 1:18554 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-8788
Practice Address - Country:US
Practice Address - Phone:231-796-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006925103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680E44501OtherBLUE CROSS BLUE SHIELD
MI039129OtherVALUE OPTIONS
MI039129OtherVALUE OPTIONS