Individual
EOLA SHELLY FOWLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3505 WESTERN AVE, KINGMAN, AZ 86409-3071
(928) 757-8111
Mailing address
3784 E SNAVELY BAY, KINGMAN, AZ 86409-0850
(775) 309-3351
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
LIAC-155347
AZ
101YM0800X
Mental Health Counselor
Primary
LCSW-22881
AZ
Other
Enumeration date
01/18/2019
Last updated
04/09/2025
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