Provider Demographics
NPI:1639232804
Name:CUSACK, NANCY MARIE (MA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:MARIE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4023 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3023
Mailing Address - Country:US
Mailing Address - Phone:612-823-6578
Mailing Address - Fax:
Practice Address - Street 1:425 COON RAPIDS BLVD NW STE 200
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2753
Practice Address - Country:US
Practice Address - Phone:763-784-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 3907103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP 37869OtherHEALTH PARTNERS
MN201945100Medicaid