Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 070024735 | IL |
N | 2251X0800X | Physical Therapist - Orthopedic | 1102679 | KS |
NPI | 1003889239 |
---|---|
Provider Name | Mrs. Angela J Cusick |
First Address | Champaign, IL 61820-3981 |
Second Address | Champaign, IL 61822-3743 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 24/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070024735 | PROFESSIONAL LICENSE (01) | IL |