Provider Demographics
NPI:1043373129
Name:CUSACK, JOHN FRANCIS (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FRANCIS
Last Name:CUSACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 HIGHLAND AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2530
Mailing Address - Country:US
Mailing Address - Phone:617-666-5800
Mailing Address - Fax:617-666-5832
Practice Address - Street 1:403 HIGHLAND AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2530
Practice Address - Country:US
Practice Address - Phone:617-666-5800
Practice Address - Fax:617-666-5832
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7105103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACUW05726OtherBCBS
MACUW50257Medicare ID - Type Unspecified