Provider Demographics
NPI:1821507229
Name:CUSACK, ARIANA MARIE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:ARIANA
Middle Name:MARIE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812-3012
Mailing Address - Country:US
Mailing Address - Phone:203-885-9122
Mailing Address - Fax:
Practice Address - Street 1:385 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-4240
Practice Address - Country:US
Practice Address - Phone:203-693-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-17-27651103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1-17-27651Medicaid