Provider Demographics
NPI:1851696033
Name:KUSY, BRYANT JUDSON (LCPC)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:JUDSON
Last Name:KUSY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1243 E IRON EAGLE DR STE 130D
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6599
Mailing Address - Country:US
Mailing Address - Phone:208-391-7050
Mailing Address - Fax:
Practice Address - Street 1:1243 E IRON EAGLE DR STE 130D
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6599
Practice Address - Country:US
Practice Address - Phone:208-391-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61806854Medicaid