Provider Demographics
NPI:1841661196
Name:CUSACK, REBECCA LYNNE (LCPC, LMHC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:LCPC, LMHC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNNE
Other - Last Name:BENEDICT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4226
Mailing Address - Country:US
Mailing Address - Phone:207-595-8335
Mailing Address - Fax:
Practice Address - Street 1:375 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804
Practice Address - Country:US
Practice Address - Phone:518-952-9032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4541101YP2500X
NY008590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional