1114274404 NPI number — TONJA R FOWLKES MSW, LSW, LICDC

Table of content: KIARA JONES (NPI 1194378463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114274404 NPI number — TONJA R FOWLKES MSW, LSW, LICDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOWLKES
Provider First Name:
TONJA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LSW, LICDC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114274404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6753 STATE RD
Provider Second Line Business Mailing Address:
COTTAGE #16
Provider Business Mailing Address City Name:
PARMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44134-4517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-345-3020
Provider Business Mailing Address Fax Number:
440-345-3019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6753 STATE RD
Provider Second Line Business Practice Location Address:
COTTAGE #16
Provider Business Practice Location Address City Name:
PARMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44134-4517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-345-3017
Provider Business Practice Location Address Fax Number:
440-345-3019
Provider Enumeration Date:
08/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  11281 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: 0701273 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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