Basic Information
| Provider Information | |||||||||
| NPI: | 1518369065 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | DERRICK | ||||||||
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| Credential: | LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 868 NEAL RD | ||||||||
| Address2: | |||||||||
| City: | REIDSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273200336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365241811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 HIGHLAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271014304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366078523 | ||||||||
| FaxNumber: | 3367730916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-16 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.