Basic Information
| Provider Information | |||||||||
| NPI: | 1801185640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER-HUMPHREY | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 WALTHAM ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024218033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818623600 | ||||||||
| FaxNumber: | 7818600589 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 WALTHAM ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024218033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818623600 | ||||||||
| FaxNumber: | 7818600589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 04/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1303287 | 05 | MA | MEDICAID | 99618201 | 01 | MA | NETWORK HEALTH | OTHER | M18633 | 01 | MA | BCBS | OTHER | 042611055 | 01 | MA | TAX ID | OTHER | 0000023532 | 01 | MA | BMC | OTHER | 1303287 | 01 | MA | MBHP | OTHER | 1004745 | 01 | MA | NHP | OTHER |