Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 7105 | MA |
NPI | 1043373129 |
---|---|
Provider Name | John Francis Cusack |
First Address | Somerville, MA 02144-2530 |
Second Address | Somerville, MA 02144-2530 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CUW05726 | BCBS (01) | MA |