Healthcare Provider Details

I. General information

NPI: 1457265209
Provider Name (Legal Business Name): MACKENLIE STOWERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 BEACON ST
FORT WAYNE IN
46805-4749
US

IV. Provider business mailing address

10063 ARBOR PARK BLVD
NEW HAVEN IN
46774-0178
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-8015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6851120167
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: