Provider Demographics
NPI:1205537594
Name:FOWLE, KENNEDY OLIVIA (LSWAIC)
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:OLIVIA
Last Name:FOWLE
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-292-2249
Mailing Address - Fax:
Practice Address - Street 1:904 7TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1132
Practice Address - Country:US
Practice Address - Phone:206-292-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASWIA.SC.613111591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical