Provider Demographics
NPI:1558016733
Name:CUSACK, SERENE (LCSW)
Entity Type:Individual
Prefix:
First Name:SERENE
Middle Name:
Last Name:CUSACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3964
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-3964
Mailing Address - Country:US
Mailing Address - Phone:406-481-4898
Mailing Address - Fax:406-327-3349
Practice Address - Street 1:900 N ORANGE ST STE 202
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-2951
Practice Address - Country:US
Practice Address - Phone:406-327-3362
Practice Address - Fax:406-327-3349
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-539101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical