Provider Demographics
NPI:1376123919
Name:CUSHINGBERRY, XIA DAE
Entity Type:Individual
Prefix:MS
First Name:XIA
Middle Name:DAE
Last Name:CUSHINGBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10645 S HALE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2758
Mailing Address - Country:US
Mailing Address - Phone:312-532-9251
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:617-863-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician