Provider Demographics
NPI:1871556803
Name:LOUSH, MARK ROBERT (LMSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBERT
Last Name:LOUSH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 GOLDENEYE LN
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-5458
Mailing Address - Country:US
Mailing Address - Phone:248-420-0832
Mailing Address - Fax:
Practice Address - Street 1:12851 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-8506
Practice Address - Country:US
Practice Address - Phone:800-529-7220
Practice Address - Fax:810-220-5521
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801059250104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker