Provider Demographics
NPI:1457115719
Name:CUSACK, PHILIP MICHAEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:MICHAEL
Last Name:CUSACK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 BYRON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-4542
Mailing Address - Country:US
Mailing Address - Phone:541-673-0609
Mailing Address - Fax:
Practice Address - Street 1:1871 NE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1433
Practice Address - Country:US
Practice Address - Phone:541-440-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR986755225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics