Provider Demographics
NPI:1255877965
Name:BAUSANO, MICHAEL JEROME (SOCIAL WORKER)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEROME
Last Name:BAUSANO
Suffix:
Gender:M
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6713 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:CANADIAN LAKES
Mailing Address - State:MI
Mailing Address - Zip Code:49346-8832
Mailing Address - Country:US
Mailing Address - Phone:231-598-0894
Mailing Address - Fax:
Practice Address - Street 1:6713 SUNSET LN
Practice Address - Street 2:
Practice Address - City:CANADIAN LAKES
Practice Address - State:MI
Practice Address - Zip Code:49346-8832
Practice Address - Country:US
Practice Address - Phone:231-598-0894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010698701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical