Healthcare Provider Details

I. General information

NPI: 1184362758
Provider Name (Legal Business Name): BENJAMIN TYLER FOWLER BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 MARGIE DR
WARNER ROBINS GA
31088-7818
US

IV. Provider business mailing address

5050 RESEARCH CT STE 125
SUWANEE GA
30024-5573
US

V. Phone/Fax

Practice location:
  • Phone: 404-410-7600
  • Fax:
Mailing address:
  • Phone: 404-410-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-90082
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: