Provider Demographics
NPI:1568884476
Name:KUSAS, MARY (RPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KUSAS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3306
Mailing Address - Country:US
Mailing Address - Phone:718-614-9854
Mailing Address - Fax:
Practice Address - Street 1:1200 SOUTH AVE STE 303
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3420
Practice Address - Country:US
Practice Address - Phone:718-818-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-11
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist