Provider Demographics
NPI:1386007839
Name:KASUBA, BRYCE (MA, LPC LADC)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:KASUBA
Suffix:
Gender:M
Credentials:MA, LPC LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2402
Mailing Address - Country:US
Mailing Address - Phone:610-212-3328
Mailing Address - Fax:
Practice Address - Street 1:40 E BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2402
Practice Address - Country:US
Practice Address - Phone:610-212-3328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT165101YA0400X
PAPC002908101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)