MEDICARE: MANDI FOWLKES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	108268	TX

General Provider Information

NPI Number	:	1083098826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDI FOWLKES

Provider Business Mailing Address
First Line	:	502 RIVER POINTE DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2838
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 RIVER POINTE DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2838
Country	:	US
Telephone Number	:	936-207-1265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2015
Last Update Date	:	07/10/2015

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