Basic Information
| Provider Information | |||||||||
| NPI: | 1366408163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUSA | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | M.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3834 BONNYBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210434134 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3421 BENSON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212271056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106441880 | ||||||||
| FaxNumber: | 4106446048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 21228 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.