Provider Demographics
NPI:1316292303
Name:FOWLKES, KEN-NETTA (BA ,MA)
Entity type:Individual
Prefix:
First Name:KEN-NETTA
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:BA ,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RODGERS PL
Mailing Address - Street 2:
Mailing Address - City:NORTH VERSAILLES
Mailing Address - State:PA
Mailing Address - Zip Code:15137-1610
Mailing Address - Country:US
Mailing Address - Phone:412-824-6548
Mailing Address - Fax:
Practice Address - Street 1:103 RODGERS PL
Practice Address - Street 2:
Practice Address - City:NORTH VERSAILLES
Practice Address - State:PA
Practice Address - Zip Code:15137-1610
Practice Address - Country:US
Practice Address - Phone:412-401-1476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172V00000XOther Service ProvidersCommunity Health Worker