Provider Demographics
NPI:1114491537
Name:FOWLER, EOLA SHELLY
Entity type:Individual
Prefix:
First Name:EOLA
Middle Name:SHELLY
Last Name:FOWLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3784 E SNAVELY BAY
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0850
Mailing Address - Country:US
Mailing Address - Phone:775-309-3351
Mailing Address - Fax:
Practice Address - Street 1:3505 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3071
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-22881101YM0800X
AZLIAC-155347101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)