Healthcare Provider Details

I. General information

NPI: 1114491537
Provider Name (Legal Business Name): EOLA SHELLY FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 04/09/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 WESTERN AVE
KINGMAN AZ
86409-3071
US

IV. Provider business mailing address

3784 E SNAVELY BAY
KINGMAN AZ
86409-0850
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-8111
  • Fax:
Mailing address:
  • Phone: 775-309-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW-22881
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-155347
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: