Provider Demographics
NPI:1679121461
Name:CUSICK, KATHLEEN MAVOURNEEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MAVOURNEEN
Last Name:CUSICK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21637 WELCH RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-2101
Mailing Address - Country:US
Mailing Address - Phone:248-719-2845
Mailing Address - Fax:
Practice Address - Street 1:135 S PROSPECT ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-7914
Practice Address - Country:US
Practice Address - Phone:248-719-2845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016433103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist