Provider Demographics
NPI:1215056924
Name:FOWLER, MICHAEL LEROY (BSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEROY
Last Name:FOWLER
Suffix:
Gender:M
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE B-100
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1619
Mailing Address - Country:US
Mailing Address - Phone:334-322-0255
Mailing Address - Fax:334-270-1187
Practice Address - Street 1:4520 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE B-100
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1619
Practice Address - Country:US
Practice Address - Phone:334-322-0255
Practice Address - Fax:334-270-1187
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4035651104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker