Provider Demographics
NPI:1770235749
Name:FOWLKS, EMMANVELLA CELESTINE
Entity Type:Individual
Prefix:
First Name:EMMANVELLA
Middle Name:CELESTINE
Last Name:FOWLKS
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 1:8505 JACKRABBIT RD STE A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-3009
Mailing Address - Country:US
Mailing Address - Phone:346-340-7182
Mailing Address - Fax:
Practice Address - Street 1:8505 JACKRABBIT RD STE A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-3009
Practice Address - Country:US
Practice Address - Phone:346-340-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBCBA753377106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician