Provider Demographics
NPI:1134904295
Name:BACCHUS, DUANE (LLMSW)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 EMBRO DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5104
Mailing Address - Country:US
Mailing Address - Phone:616-238-9086
Mailing Address - Fax:
Practice Address - Street 1:327 RUMSEY ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4935
Practice Address - Country:US
Practice Address - Phone:616-819-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511155191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical