Provider Demographics
NPI:1164694030
Name:BOUSAMRA, CHAD THOMAS (MA)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:THOMAS
Last Name:BOUSAMRA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 E EIGHTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2936
Mailing Address - Country:US
Mailing Address - Phone:231-935-6787
Mailing Address - Fax:231-935-6920
Practice Address - Street 1:1105 E EIGHTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2936
Practice Address - Country:US
Practice Address - Phone:231-935-6787
Practice Address - Fax:231-935-6920
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010758101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)