Basic Information
| Provider Information | |||||||||
| NPI: | 1972145365 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSACK | ||||||||
| FirstName: | RUDORWASHE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHESTNUT ST APT 214 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013689100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 154 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028954469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083734074 | ||||||||
| FaxNumber: | 4012359064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2019 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.