Provider Demographics
NPI:1336469501
Name:KUSIAK, MARY JO ANN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY JO
Middle Name:ANN
Last Name:KUSIAK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 PEPPERVINE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7710
Mailing Address - Country:US
Mailing Address - Phone:407-963-9511
Mailing Address - Fax:407-482-2304
Practice Address - Street 1:3907 PEPPERVINE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7710
Practice Address - Country:US
Practice Address - Phone:407-963-9511
Practice Address - Fax:407-482-2304
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 76281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical