=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881990950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIESHEKIA FOWLKS-
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2011
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3776 LAVISTA RD STE 350
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-5648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-914-8877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 473
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021-0473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-914-8877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 005832
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------