Provider Demographics
NPI:1366099665
Name:BAUSLEY, WAVERLY MAURICE
Entity type:Individual
Prefix:
First Name:WAVERLY
Middle Name:MAURICE
Last Name:BAUSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25740 SHIAWASSEE RD APT 123
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3743
Mailing Address - Country:US
Mailing Address - Phone:810-986-7348
Mailing Address - Fax:
Practice Address - Street 1:22170 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6007
Practice Address - Country:US
Practice Address - Phone:248-372-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator