Provider Demographics
NPI:1356458145
Name:MITCHELL CUSICK, CAROL (LCPC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:MITCHELL CUSICK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5735
Mailing Address - Country:US
Mailing Address - Phone:207-626-3448
Mailing Address - Fax:207-626-3453
Practice Address - Street 1:10 CALDWELL RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5735
Practice Address - Country:US
Practice Address - Phone:207-626-3448
Practice Address - Fax:207-626-3453
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC509101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME01-0288363OtherAGENCY TAX ID NUMBER