Provider Demographics
NPI:1760881080
Name:FOWLKES, GLENN (LPC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:BURKEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23922-3524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MILL ST
Practice Address - Street 2:#102
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-3401
Practice Address - Country:US
Practice Address - Phone:434-298-7318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional