Provider Demographics
NPI:1407953326
Name:NUSSBAUM, CHERYL L (MSW, LSCSW)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:MSW, LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 N ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3273
Mailing Address - Country:US
Mailing Address - Phone:316-684-5448
Mailing Address - Fax:316-684-5448
Practice Address - Street 1:3425 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-4919
Practice Address - Country:US
Practice Address - Phone:316-650-8885
Practice Address - Fax:316-943-1139
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 08571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS011380Medicare ID - Type UnspecifiedBCBS PROVIDER NUMBER