Provider Demographics
NPI:1346259157
Name:CUSHING, KYLE J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:CUSHING
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 1:2823 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-3542
Mailing Address - Country:US
Mailing Address - Phone:815-968-5342
Mailing Address - Fax:815-968-4656
Practice Address - Street 1:2823 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-3542
Practice Address - Country:US
Practice Address - Phone:815-968-5342
Practice Address - Fax:815-968-4656
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006072103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0010126129OtherBLUE CROSS/BLUE SHIELD
IL581860Medicare ID - Type Unspecified