Provider Demographics
NPI:1265509467
Name:CUSACK, JULIE S (PT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:S
Last Name:CUSACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:S
Other - Last Name:LAWS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:380 EMPIRE RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2677
Mailing Address - Country:US
Mailing Address - Phone:720-890-1091
Mailing Address - Fax:
Practice Address - Street 1:380 EMPIRE RD
Practice Address - Street 2:SUITE 230
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2677
Practice Address - Country:US
Practice Address - Phone:720-890-1091
Practice Address - Fax:720-890-1098
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010363225100000X
COPTL.0011465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619980OtherBCBS OF IL
ILK52401Medicare PIN
ILK52399Medicare PIN
IL568080Medicare PIN
ILK52400Medicare PIN
IL1619980OtherBCBS OF IL
K23931Medicare UPIN
IL568150Medicare PIN