Provider Demographics
NPI:1619594892
Name:ROUSH, MADISON MACKENZIE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MACKENZIE
Last Name:ROUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59764 BARKLEY DR
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9659
Mailing Address - Country:US
Mailing Address - Phone:248-804-3122
Mailing Address - Fax:
Practice Address - Street 1:2280 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8503
Practice Address - Country:US
Practice Address - Phone:517-546-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802090870104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker