Provider Demographics
NPI:1083965206
Name:FOWKES, AMY LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:FOWKES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10408 SHADOW RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1299
Mailing Address - Country:US
Mailing Address - Phone:412-770-4181
Mailing Address - Fax:
Practice Address - Street 1:6200 CRESTWOOD STA
Practice Address - Street 2:SUITE A
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-7418
Practice Address - Country:US
Practice Address - Phone:502-243-2622
Practice Address - Fax:502-243-2692
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2011-100103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling