Provider Demographics
NPI:1306328281
Name:FOWLKES, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 W 190TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4223
Mailing Address - Country:US
Mailing Address - Phone:310-323-6887
Mailing Address - Fax:
Practice Address - Street 1:879 W 190TH ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4220
Practice Address - Country:US
Practice Address - Phone:310-323-6887
Practice Address - Fax:714-680-8233
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X, 390200000X
CAASW996621041C0700X
CA1185451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program