Healthcare Provider Details

I. General information

NPI: 1336290634
Provider Name (Legal Business Name): MATTHEW BERNARD DUSSIA LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5818 N COOLIDGE AVE
HARRISON MI
48625-8679
US

IV. Provider business mailing address

5818 N COOLIDGE AVE
HARRISON MI
48625-8679
US

V. Phone/Fax

Practice location:
  • Phone: 989-539-3841
  • Fax:
Mailing address:
  • Phone: 989-430-7495
  • Fax: 989-539-2143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801058358
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: