Provider Demographics
NPI:1629728795
Name:CUSICK, MICHELLE (LCSWA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CUSICK
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:CUSICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWA
Mailing Address - Street 1:1650 GREENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6456
Mailing Address - Country:US
Mailing Address - Phone:310-795-4070
Mailing Address - Fax:
Practice Address - Street 1:1650 GREENFIELD ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6456
Practice Address - Country:US
Practice Address - Phone:310-795-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0171901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical