Provider Demographics
NPI:1962073544
Name:FOWLER, TEISHA (LCMHCA)
Entity type:Individual
Prefix:
First Name:TEISHA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7008 IDLEWILD BROOK LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-5855
Mailing Address - Country:US
Mailing Address - Phone:317-480-9419
Mailing Address - Fax:
Practice Address - Street 1:2040 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1236
Practice Address - Country:US
Practice Address - Phone:980-219-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16734101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional