MEDICARE: DR. LISA J. CUSHMAN M.S., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1093797565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA J. CUSHMAN M.S., PH.D.

Provider Business Mailing Address
First Line	:	5662 PRIMROSE AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-3341
Country	:	US
Telephone Number	:	317-465-0998
Fax Number	:

Provider Business Practice Location Address
First Line	:	975 W WALNUT ST
Second Line	:	IB 130
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5181
Country	:	US
Telephone Number	:	317-274-2450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	07/08/2007

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