MEDICARE: FOWLER PSYCHOLOGICAL SERVICES, INC.

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	251S00000X	Community/Behavioral Health Agency	LP1765	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	620000219	OTHER	MN	MEDICARE

General Provider Information

NPI Number	:	1477709392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOWLER PSYCHOLOGICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	5353 GAMBLE DR
Second Line	:	108
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1509
Country	:	US
Telephone Number	:	952-545-8833
Fax Number	:	952-224-2299

Provider Business Practice Location Address
First Line	:	5353 GAMBLE DR
Second Line	:	108
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-1509
Country	:	US
Telephone Number	:	952-545-8833
Fax Number	:	952-224-2299

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN RICHARD FOWLER
Credential	:	PHD
Telephone Number	:	952-545-8833

Provider Enumeration Date	:	08/12/2008
Last Update Date	:	08/12/2008

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