Provider Demographics
NPI:1609313394
Name:LECUSSAN, ROB JAMES I
Entity Type:Individual
Prefix:
First Name:ROB
Middle Name:JAMES
Last Name:LECUSSAN
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:JAMES
Other - Last Name:LECUSSAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:232 E GISH RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-4706
Mailing Address - Country:US
Mailing Address - Phone:408-453-7616
Mailing Address - Fax:
Practice Address - Street 1:232 E GISH RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4706
Practice Address - Country:US
Practice Address - Phone:408-453-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88706106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist