Provider Demographics
NPI:1003320243
Name:KUSSIN, KENNETH DAVID
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:KUSSIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CONIFER LN
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966
Mailing Address - Country:US
Mailing Address - Phone:618-559-3342
Mailing Address - Fax:
Practice Address - Street 1:48 CONIFER LN
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-5242
Practice Address - Country:US
Practice Address - Phone:618-559-3342
Practice Address - Fax:618-559-3342
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool