Provider Demographics
NPI:1881990950
Name:FOWLKS-, TIESHEKIA
Entity type:Individual
Prefix:
First Name:TIESHEKIA
Middle Name:
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:PO BOX 473
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-0473
Mailing Address - Country:US
Mailing Address - Phone:404-914-8877
Mailing Address - Fax:
Practice Address - Street 1:3776 LAVISTA RD STE 350
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5648
Practice Address - Country:US
Practice Address - Phone:404-914-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005832101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional