Provider Demographics
NPI:1720351117
Name:NUSBAUM, MARY ANN (PHD)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 WARD RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80002-1832
Mailing Address - Country:US
Mailing Address - Phone:303-278-7418
Mailing Address - Fax:888-341-5050
Practice Address - Street 1:4738 W COUNTY ROAD 400 S
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-8371
Practice Address - Country:US
Practice Address - Phone:574-339-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042168A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20042168AOtherPROFESSIONAL LICENSE