Basic Information
| Provider Information | |||||||||
| NPI: | 1023630076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUSACK | ||||||||
| FirstName: | INDIA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112232329 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112232329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186764260 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2020 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.