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General NPI Number Information
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NPI Number | 1780220475
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Entity Type | Individual
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Provider Name | MICHAEL DEAN FLEETWOOD CADC
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Gender | Male
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Dates
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Enumeration Date | 11/18/2019
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Last Update Date | 11/18/2019
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Provider Practice Location Address
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Address Line | 1824 S VAN BUREN ST
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City | ENID
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State | OK
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Zip | 73703-7903
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Country | US
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Telephone | 580-540-8965
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Fax |
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Provider Business Mailing Address
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Address Line | 2113 NE 15TH ST
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City | MOORE
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State | OK
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Zip | 73160-8625
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Country | US
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Telephone | 52-038-5294
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 164
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License Number State | OK
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