Provider Demographics
NPI:1972145365
Name:CUSACK, RUDORWASHE ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:RUDORWASHE
Middle Name:ELIZABETH
Last Name:CUSACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHESTNUT ST APT 214
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4123
Mailing Address - Country:US
Mailing Address - Phone:401-368-9100
Mailing Address - Fax:
Practice Address - Street 1:154 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4469
Practice Address - Country:US
Practice Address - Phone:508-373-4074
Practice Address - Fax:401-235-9064
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health