Healthcare Provider Details

I. General information

NPI: 1396480224
Provider Name (Legal Business Name): CHASE T BOUSCHOR LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 GREENFIELD RD STE 300
DEARBORN MI
48120-1805
US

IV. Provider business mailing address

3200 GREENFIELD RD STE 300
DEARBORN MI
48120-1805
US

V. Phone/Fax

Practice location:
  • Phone: 646-453-6777
  • Fax:
Mailing address:
  • Phone: 646-453-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801122172
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: