Provider Demographics
NPI:1568286789
Name:CUSSON, IAN (PHD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:CUSSON
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 1:619 NW MARKET ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1914 N 34TH ST STE 206
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-9089
Practice Address - Country:US
Practice Address - Phone:206-594-0577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61603244103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical