Provider Demographics
NPI:1114274404
Name:FOWLKES, TONJA R (MSW, LSW, LICDC)
Entity Type:Individual
Prefix:
First Name:TONJA
Middle Name:R
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:MSW, LSW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6753 STATE RD
Mailing Address - Street 2:COTTAGE #16
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-4517
Mailing Address - Country:US
Mailing Address - Phone:440-345-3020
Mailing Address - Fax:440-345-3019
Practice Address - Street 1:6753 STATE RD
Practice Address - Street 2:COTTAGE #16
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-4517
Practice Address - Country:US
Practice Address - Phone:440-345-3017
Practice Address - Fax:440-345-3019
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11281101YA0400X
OH0701273104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker