Provider Demographics
NPI:1699259184
Name:CUSACK, KERRIE ANN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KERRIE
Middle Name:ANN
Last Name:CUSACK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BLACKSTONE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02019-1601
Mailing Address - Country:US
Mailing Address - Phone:508-657-0117
Mailing Address - Fax:
Practice Address - Street 1:21 BLACKSTONE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019-1601
Practice Address - Country:US
Practice Address - Phone:774-571-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4289651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical