Healthcare Provider Details

I. General information

NPI: 1801778378
Provider Name (Legal Business Name): SCOTT FOWLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N 5TH ST
GOSHEN IN
46528-3226
US

IV. Provider business mailing address

1111 COURT LN APT B
GOSHEN IN
46526-4483
US

V. Phone/Fax

Practice location:
  • Phone: 574-349-4796
  • Fax:
Mailing address:
  • Phone: 574-903-3537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-456628
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: