Provider Demographics
NPI:1376767491
Name:KUSICK, BRADLEY ROBERT (MA LPC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ROBERT
Last Name:KUSICK
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 BURBANK ST STE C
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1658
Mailing Address - Country:US
Mailing Address - Phone:303-907-3475
Mailing Address - Fax:
Practice Address - Street 1:710 BURBANK ST STE C
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1658
Practice Address - Country:US
Practice Address - Phone:303-907-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO585101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86602560Medicaid