Healthcare Provider Details

I. General information

NPI: 1871165720
Provider Name (Legal Business Name): FAMILY RESTORATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 VANDERBILT CT
BOWLING GREEN KY
42103-7020
US

IV. Provider business mailing address

1103 HOMESTEAD CT
BOWLING GREEN KY
42104-4122
US

V. Phone/Fax

Practice location:
  • Phone: 270-535-4516
  • Fax:
Mailing address:
  • Phone: 270-779-9677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM LEE FOWLKES
Title or Position: DIRECTOR
Credential: LCSW
Phone: 270-535-4516