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General NPI Number Information
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NPI Number | 1619347085
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Entity Type | Individual
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Provider Name | ROLLIN DESEAN FOWLKES JR. OTRL
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Gender | Male
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Dates
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Enumeration Date | 09/29/2015
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Last Update Date | 04/13/2016
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Provider Practice Location Address
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Address Line | 34330 VAN BORN RD
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City | WAYNE
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State | MI
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Zip | 48184-2472
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Country | US
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Telephone | 313-287-0057
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Fax |
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Provider Business Mailing Address
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Address Line | 34330 VAN BORN RD
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City | WAYNE
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State | MI
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Zip | 48184-2472
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Country | US
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Telephone | 313-287-0057
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 5201008622
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License Number State | MI
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