Provider Demographics
NPI:1619347085
Name:FOWLKES, ROLLIN DESEAN JR (OTRL)
Entity Type:Individual
Prefix:MR
First Name:ROLLIN
Middle Name:DESEAN
Last Name:FOWLKES
Suffix:JR
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34330 VAN BORN RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2472
Mailing Address - Country:US
Mailing Address - Phone:313-287-0057
Mailing Address - Fax:
Practice Address - Street 1:34330 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2472
Practice Address - Country:US
Practice Address - Phone:313-287-0057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008622225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist