Provider Demographics
NPI:1992396188
Name:CUSACK, MAE HELEN
Entity Type:Individual
Prefix:MISS
First Name:MAE
Middle Name:HELEN
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 1:673 SAN JOSE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4914
Mailing Address - Country:US
Mailing Address - Phone:415-282-3769
Mailing Address - Fax:
Practice Address - Street 1:673 SAN JOSE AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4914
Practice Address - Country:US
Practice Address - Phone:415-282-3769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2080P0008X2084B0040X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty