Basic Information
| Provider Information | |||||||||
| NPI: | 1336290634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUSSIA | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5818 N COOLIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486258679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894307495 | ||||||||
| FaxNumber: | 9895392143 | ||||||||
| Practice Location | |||||||||
| Address1: | 5818 N COOLIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486258679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895393841 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801058358 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.