Provider Demographics
NPI:1992903363
Name:DR BRUCE A FOWLER P C
Entity type:Organization
Organization Name:DR BRUCE A FOWLER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:616-450-4601
Mailing Address - Street 1:2090 CELEBRATION DR NE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9200
Mailing Address - Country:US
Mailing Address - Phone:616-450-4601
Mailing Address - Fax:616-608-0108
Practice Address - Street 1:2090 CELEBRATION DR NE
Practice Address - Street 2:SUITE 212
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9200
Practice Address - Country:US
Practice Address - Phone:616-450-4601
Practice Address - Fax:616-608-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006137103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P46746001Medicare PIN