Provider Demographics
NPI:1184215204
Name:GUSH, MICHAEL JAMES (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:GUSH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23937 SW RED FERN DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-6283
Mailing Address - Country:US
Mailing Address - Phone:805-276-0764
Mailing Address - Fax:
Practice Address - Street 1:1800 NE MARKET DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-7000
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL102991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL10299OtherLICENSED CLINICAL SOCIAL WORKER