Provider Demographics
NPI:1659145860
Name:CUSACK, CAITILIN CASSIDY (RBT)
Entity Type:Individual
Prefix:
First Name:CAITILIN
Middle Name:CASSIDY
Last Name:CUSACK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 N MILWAUKEE AVE APT 10A
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3915
Mailing Address - Country:US
Mailing Address - Phone:224-294-4052
Mailing Address - Fax:
Practice Address - Street 1:1585 N MILWAUKEE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1359
Practice Address - Country:US
Practice Address - Phone:847-918-7947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-23-308795106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician