Provider Demographics
NPI:1063574077
Name:CUSHMAN, DOUGLAS WOOD (L M S W)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:WOOD
Last Name:CUSHMAN
Suffix:
Gender:M
Credentials:L M S W
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 VERMONT AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1807
Mailing Address - Country:US
Mailing Address - Phone:616-897-5900
Mailing Address - Fax:616-897-5954
Practice Address - Street 1:11652 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MI
Practice Address - Zip Code:49331-9203
Practice Address - Country:US
Practice Address - Phone:616-897-5900
Practice Address - Fax:616-897-5954
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010614671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical