Provider Demographics
NPI:1467659201
Name:CUSICK, STACEY (LSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:CUSICK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:BRICKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 715194
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-5194
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-0509
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-8212
Practice Address - Fax:614-722-3235
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS00317211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicare UPIN