Provider Demographics
NPI:1881792497
Name:FOWLER, BRUCE ALLEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 CELEBRATION DR NE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9200
Mailing Address - Country:US
Mailing Address - Phone:616-450-4601
Mailing Address - Fax:616-608-0108
Practice Address - Street 1:2090 CELEBRATION DR NE
Practice Address - Street 2:SUITE 212
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9200
Practice Address - Country:US
Practice Address - Phone:616-450-4601
Practice Address - Fax:616-608-0108
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006137103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680D115690OtherBLUE CROSS BLUE SHIELD MI
MI680D115690OtherBLUE CROSS BLUE SHIELD MI