Provider Demographics
NPI:1386356236
Name:FOWLKES, CRYSTAL LORRAINE (BT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LORRAINE
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5812 DUNKIRK ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3128
Mailing Address - Country:US
Mailing Address - Phone:757-578-6003
Mailing Address - Fax:
Practice Address - Street 1:6325 N CENTER DR STE 121
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-0012
Practice Address - Country:US
Practice Address - Phone:757-901-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician