Healthcare Provider Details

I. General information

NPI: 1144061193
Provider Name (Legal Business Name): KRYSTAL MARY FOWLER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 CORPORATION LN STE 245
VIRGINIA BEACH VA
23462-3676
US

IV. Provider business mailing address

4445 CORPORATION LN STE 245
VIRGINIA BEACH VA
23462-3676
US

V. Phone/Fax

Practice location:
  • Phone: 757-233-0003
  • Fax:
Mailing address:
  • Phone: 757-233-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701015161
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: