MEDICARE: TONJA R FOWLKES MSW, LSW, LICDC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	11281	OH
2	104100000X	Social Worker	0701273	OH

General Provider Information

NPI Number	:	1114274404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONJA R FOWLKES MSW, LSW, LICDC

Provider Business Mailing Address
First Line	:	6753 STATE RD
Second Line	:	COTTAGE #16
City	:	PARMA
State	:	OH
Zip	:	44134-4517
Country	:	US
Telephone Number	:	440-345-3020
Fax Number	:	440-345-3019

Provider Business Practice Location Address
First Line	:	6753 STATE RD
Second Line	:	COTTAGE #16
City	:	PARMA
State	:	OH
Zip	:	44134-4517
Country	:	US
Telephone Number	:	440-345-3017
Fax Number	:	440-345-3019

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

Provider Enumeration Date	:	08/06/2012
Last Update Date	:	07/14/2015

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