Provider Demographics
NPI:1497226385
Name:FOWLKES, MICHAEL ANTHONY (101YM0800X)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:FOWLKES
Suffix:
Gender:M
Credentials:101YM0800X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 HILL RD APT 201
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-4340
Mailing Address - Country:US
Mailing Address - Phone:771-777-0516
Mailing Address - Fax:
Practice Address - Street 1:906 HILL RD APT 201
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4340
Practice Address - Country:US
Practice Address - Phone:771-777-0516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCAC11019101YM0800X
DC1019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)