Provider Demographics
NPI:1831690593
Name:FOWLKES, LATOSHA R (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LATOSHA
Middle Name:R
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LATOSHA
Other - Middle Name:R
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1260 LYNFIELD PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63147-1516
Mailing Address - Country:US
Mailing Address - Phone:314-565-6822
Mailing Address - Fax:
Practice Address - Street 1:1260 LYNFIELD PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63147-1516
Practice Address - Country:US
Practice Address - Phone:314-565-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019003940101YM0800X
IL149.019998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health