Provider Demographics
NPI:1669699856
Name:FOWLER, BRYAN LYNN (LLMSW)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:LYNN
Last Name:FOWLER
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43100 12 OAKS CRESCENT DR APT 6011
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3438
Mailing Address - Country:US
Mailing Address - Phone:734-730-2007
Mailing Address - Fax:
Practice Address - Street 1:220 BAGLEY STE 1100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48266-0001
Practice Address - Country:US
Practice Address - Phone:313-961-7990
Practice Address - Fax:313-961-6274
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010873821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical