Provider Demographics
NPI:1700210101
Name:FOWLES, CHERISSE A
Entity Type:Individual
Prefix:MS
First Name:CHERISSE
Middle Name:A
Last Name:FOWLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2877 DEERWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5506
Mailing Address - Country:US
Mailing Address - Phone:678-522-7155
Mailing Address - Fax:
Practice Address - Street 1:652 HOPE HOLLOW LN
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6213
Practice Address - Country:US
Practice Address - Phone:866-770-7294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP 008253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist