Provider Demographics
NPI:1639157050
Name:KUSIAK, KIMBERLEE A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:A
Last Name:KUSIAK
Suffix:
Gender:F
Credentials:MD
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA762832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3109615Medicaid
MAF56340Medicare UPIN
MA3109615Medicaid