Provider Demographics
NPI:1104308675
Name:CUSUMANO, JUSTIN (MA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CUSUMANO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3466 FORT NELSON LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-2902
Mailing Address - Country:US
Mailing Address - Phone:321-872-4660
Mailing Address - Fax:
Practice Address - Street 1:5545 N WICKHAM RD STE 110
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7323
Practice Address - Country:US
Practice Address - Phone:321-872-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator