Healthcare Provider Details

I. General information

NPI: 1962860726
Provider Name (Legal Business Name): ANGELA FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 CONNECTICUT ST
MERRILLVILLE IN
46410-6647
US

IV. Provider business mailing address

8601 CONNECTICUT ST
MERRILLVILLE IN
46410-6647
US

V. Phone/Fax

Practice location:
  • Phone: 219-525-3495
  • Fax: 219-472-0934
Mailing address:
  • Phone: 219-525-3495
  • Fax: 219-472-0934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001659A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: