Provider Demographics
NPI:1497272975
Name:FELLOWS, AUDREY RENEE (LMHC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:RENEE
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:RENEE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:912 E LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2817
Mailing Address - Country:US
Mailing Address - Phone:574-231-8000
Mailing Address - Fax:574-231-8013
Practice Address - Street 1:912 E LASALLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2817
Practice Address - Country:US
Practice Address - Phone:574-231-8000
Practice Address - Fax:574-231-8013
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003063A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health