Provider Demographics
NPI:1205238201
Name:WASHBURN, MICHAEL (MM, MA, CSAT-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:MM, MA, CSAT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20505 MILBURN ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1619
Mailing Address - Country:US
Mailing Address - Phone:586-215-9564
Mailing Address - Fax:
Practice Address - Street 1:11111 HALL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5711
Practice Address - Country:US
Practice Address - Phone:586-997-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014327101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional