Healthcare Provider Details

I. General information

NPI: 1770446452
Provider Name (Legal Business Name): KIRSTY FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2206A WRIGHTSVILLE AVE
WILMINGTON NC
28403-2406
US

IV. Provider business mailing address

4817 WILDERNESS RD
WILMINGTON NC
28412-7635
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-6499
  • Fax:
Mailing address:
  • Phone: 401-575-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: