Healthcare Provider Details

I. General information

NPI: 1205238201
Provider Name (Legal Business Name): MICHAEL WASHBURN M.M., M.A., CSAT-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 HALL RD SUITE 300
UTICA MI
48317-5711
US

IV. Provider business mailing address

20505 MILBURN ST
LIVONIA MI
48152-1619
US

V. Phone/Fax

Practice location:
  • Phone: 586-997-3153
  • Fax:
Mailing address:
  • Phone: 586-215-9564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014327
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: