Provider Demographics
NPI:1851059430
Name:FOWLKES, SAMANTHA (LPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 BALTIMORE PIKE STE 1249
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-3810
Mailing Address - Country:US
Mailing Address - Phone:484-836-9016
Mailing Address - Fax:
Practice Address - Street 1:110 SOUTH 2ND ST
Practice Address - Street 2:
Practice Address - City:COLWYN
Practice Address - State:PA
Practice Address - Zip Code:19023
Practice Address - Country:US
Practice Address - Phone:484-836-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPC013981101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health