Provider Demographics
NPI:1730301680
Name:MCCUSKER, MARY P (MED, LMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:MCCUSKER
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ASHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1604
Mailing Address - Country:US
Mailing Address - Phone:617-504-0488
Mailing Address - Fax:617-983-4658
Practice Address - Street 1:1155 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3432
Practice Address - Country:US
Practice Address - Phone:617-983-7639
Practice Address - Fax:617-983-4658
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1964101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health