Provider Demographics
NPI:1225645294
Name:BOURGOISE, MICHAEL L (LMSW-C, CAADC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BOURGOISE
Suffix:
Gender:M
Credentials:LMSW-C, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6740 CENTRAL CITY PKWY
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-9138
Mailing Address - Country:US
Mailing Address - Phone:216-543-6814
Mailing Address - Fax:
Practice Address - Street 1:6740 CENTRAL CITY PKWY
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-9138
Practice Address - Country:US
Practice Address - Phone:216-543-6814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2023-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-04880101YA0400X
MI68011146101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)