1962415836 NPI number — MR. SCOTT MATTHEW FOWLER LPC, LMFT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962415836 NPI number — MR. SCOTT MATTHEW FOWLER LPC, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOWLER
Provider First Name:
SCOTT
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC, LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962415836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 MARY BIERBAUER WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORKTOWN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23693-2037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-753-8402
Provider Business Mailing Address Fax Number:
757-223-9783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 PILOT HOUSE DR
Provider Second Line Business Practice Location Address:
SUITE 100A
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23606-1993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-223-7821
Provider Business Practice Location Address Fax Number:
757-223-9783
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0701003208 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 0717001125 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010377731 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010370736 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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