Provider Demographics
NPI:1457133571
Name:KUSICH, CASEY LYNN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNN
Last Name:KUSICH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11623 HARMONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-6333
Mailing Address - Country:US
Mailing Address - Phone:724-813-1289
Mailing Address - Fax:
Practice Address - Street 1:11623 HARMONSBURG RD
Practice Address - Street 2:
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-6333
Practice Address - Country:US
Practice Address - Phone:724-813-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered