Provider Demographics
NPI:1780220475
Name:FLEETWOOD, MICHAEL DEAN (CADC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:FLEETWOOD
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-8625
Mailing Address - Country:US
Mailing Address - Phone:052-038-5294
Mailing Address - Fax:
Practice Address - Street 1:1824 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-7903
Practice Address - Country:US
Practice Address - Phone:580-540-8965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK164101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty