Provider Demographics
NPI:1891747960
Name:SHUSHANSKY, LARRY M (LICSW)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:M
Last Name:SHUSHANSKY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 BUTLER AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5317
Mailing Address - Country:US
Mailing Address - Phone:401-829-1209
Mailing Address - Fax:
Practice Address - Street 1:182 BUTLER AVE STE 4
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-298-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW003911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI407868OtherBLUE CHIP PROVIDER #
RI30328-8OtherBLUE SHIELD PROVIDER #