Provider Demographics
NPI:1215239801
Name:CUSICK, GARY MATTHEW (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MATTHEW
Last Name:CUSICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 HOLSWORTH LANE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1206 HOLSWORTH LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6616
Practice Address - Country:US
Practice Address - Phone:502-439-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1344101YM0800X, 103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities