MEDICARE: DR. SUSAN H FOWLER PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301006925	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680E44501	OTHER	MI	BLUE CROSS BLUE SHIELD
2	039129	OTHER	MI	VALUE OPTIONS

General Provider Information

NPI Number	:	1881738276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN H FOWLER PSYD

Provider Business Mailing Address
First Line	:	PO BOX 511
Second Line	:
City	:	BIG RAPIDS
State	:	MI
Zip	:	49307-0511
Country	:	US
Telephone Number	:	231-796-3339
Fax Number	:

Provider Business Practice Location Address
First Line	:	18554 NORTHLAND DR
Second Line	:
City	:	BIG RAPIDS
State	:	MI
Zip	:	49307-8788
Country	:	US
Telephone Number	:	231-796-3339
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2007
Last Update Date	:	07/17/2013

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