Provider Demographics
NPI:1992050728
Name:FOWLKES, CHASITY SHANELL (LMHC, CAP)
Entity type:Individual
Prefix:
First Name:CHASITY
Middle Name:SHANELL
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:LMHC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11582 SW VILLAGE PKWY # 1137
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2392
Mailing Address - Country:US
Mailing Address - Phone:772-208-7834
Mailing Address - Fax:772-607-5295
Practice Address - Street 1:2814 S US HIGHWAY 1
Practice Address - Street 2:SUITE D4
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8120
Practice Address - Country:US
Practice Address - Phone:863-669-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X
FLMH12547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)