Provider Demographics
NPI:1518369065
Name:FOWLER, DERRICK (MSRC, LCAS, LCMHC)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MSRC, LCAS, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 ERIC LN STE D3
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5076
Mailing Address - Country:US
Mailing Address - Phone:336-520-2270
Mailing Address - Fax:336-800-3735
Practice Address - Street 1:2602 ERIC LN STE D3
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5076
Practice Address - Country:US
Practice Address - Phone:336-520-2270
Practice Address - Fax:336-800-3735
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3549101YA0400X
NC13130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)