Provider Demographics
NPI:1275850760
Name:FOWLER, LATISHA M (PHD)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:M
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 WESLEY CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-7158
Mailing Address - Country:US
Mailing Address - Phone:740-221-5085
Mailing Address - Fax:740-281-1778
Practice Address - Street 1:68 W CHURCH ST STE 318
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5050
Practice Address - Country:US
Practice Address - Phone:740-281-1777
Practice Address - Fax:740-281-1778
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211419Medicaid