Provider Demographics
NPI:1790023349
Name:CUSACK, ELIZABETH A (MA, LPC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:CUSACK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 NEW DEHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2625
Mailing Address - Country:US
Mailing Address - Phone:215-510-1891
Mailing Address - Fax:
Practice Address - Street 1:327 NEW DEHAVEN ST
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-2625
Practice Address - Country:US
Practice Address - Phone:215-510-1891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2016-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007432101YP2500X, 101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)