Provider Demographics
NPI:1578195137
Name:BOUSE, MATTHEW MAXIMINO (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MAXIMINO
Last Name:BOUSE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E LIBERTY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2156
Mailing Address - Country:US
Mailing Address - Phone:734-585-6966
Mailing Address - Fax:734-405-6314
Practice Address - Street 1:120 E LIBERTY ST STE 200
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2156
Practice Address - Country:US
Practice Address - Phone:734-585-6966
Practice Address - Fax:734-405-6314
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011159951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty