Provider Demographics
NPI:1851714216
Name:CUSON, MARY JO (MS,LAT,ATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:CUSON
Suffix:
Gender:F
Credentials:MS,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 ICE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808
Mailing Address - Country:US
Mailing Address - Phone:419-902-4973
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808
Practice Address - Country:US
Practice Address - Phone:419-902-4973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001764A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer