Healthcare Provider Details

I. General information

NPI: 1205601929
Provider Name (Legal Business Name): WILLIAM LEE FOWLKES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 DESTINY LN STE 110
BOWLING GREEN KY
42104-1088
US

IV. Provider business mailing address

1103 HOMESTEAD CT
BOWLING GREEN KY
42104-4122
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-6567
  • Fax:
Mailing address:
  • Phone: 270-535-4516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number252309
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: