Provider Demographics
NPI:1851325815
Name:AVRUSHIN, JEROME X (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:X
Last Name:AVRUSHIN
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 1:7256 CREEKS BEND CT
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3523
Mailing Address - Country:US
Mailing Address - Phone:248-539-0639
Mailing Address - Fax:
Practice Address - Street 1:6770 DIXIE HWY
Practice Address - Street 2:SUITE 312
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2087
Practice Address - Country:US
Practice Address - Phone:248-922-2300
Practice Address - Fax:248-922-2304
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010114811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOQ26429-038Medicare ID - Type UnspecifiedSOCIAL WORK