Basic Information
| Provider Information | |||||||||
| NPI: | 1477145217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOWELL | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED., CIDDT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3407 SHAMROCK CT | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395535337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284970690 | ||||||||
| FaxNumber: | 2284971363 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 DOLPHIN DR | ||||||||
| Address2: | |||||||||
| City: | GAUTIER | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395536457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284979468 | ||||||||
| FaxNumber: | 2284979471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2021 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 00770256 | 05 | MS | MEDICAID |