Provider Demographics
NPI:1801778378
Name:FOWLER, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
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 1:1111 COURT LN APT B
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4483
Mailing Address - Country:US
Mailing Address - Phone:574-903-3537
Mailing Address - Fax:
Practice Address - Street 1:203 N 5TH ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-3226
Practice Address - Country:US
Practice Address - Phone:574-349-4796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-456628106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty