Provider Demographics
NPI:1417482316
Name:CHUSAN, GINA C (LMSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:C
Last Name:CHUSAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:C
Other - Last Name:CHUSAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:837 LONGFELLOW AVE APT E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10474-4839
Mailing Address - Country:US
Mailing Address - Phone:646-281-3667
Mailing Address - Fax:
Practice Address - Street 1:837 LONGFELLOW AVE APT E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10474-4839
Practice Address - Country:US
Practice Address - Phone:646-281-3667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1002841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid