Provider Demographics
NPI:1154635571
Name:CUSHMAN, DAVID GAGE (PSYD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GAGE
Last Name:CUSHMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 BELLEVUE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4923
Mailing Address - Country:US
Mailing Address - Phone:415-841-2481
Mailing Address - Fax:
Practice Address - Street 1:445 BELLEVUE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4923
Practice Address - Country:US
Practice Address - Phone:415-841-2481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X, 103T00000X
CACA PSY 28312103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist