Provider Demographics
NPI:1689163347
Name:FOWLER-KOBYLEWSKI, LISA BROOK (RBT # 18-48630)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:BROOK
Last Name:FOWLER-KOBYLEWSKI
Suffix:
Gender:F
Credentials:RBT # 18-48630
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7596 DENRICK RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9708
Mailing Address - Country:US
Mailing Address - Phone:815-914-8215
Mailing Address - Fax:
Practice Address - Street 1:9500 BORMET DR STE 201
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8399
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-48630106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician