Basic Information
| Provider Information | |||||||||
| NPI: | 1740796564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COWICK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CADC-CAS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COWICK | ||||||||
| OtherFirstName: | MIKE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CADC-CAS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8633 KNOTT AVE | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906203852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145276561 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12531 HARBOR BLVD STE G | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928405824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146385008 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | C23961214 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
No ID Information.