Healthcare Provider Details

I. General information

NPI: 1013837202
Provider Name (Legal Business Name): MONIQUE RENEE MCCUSKER MSCCCSLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 OAK DR
ELIZABETHTOWN KY
42701-2725
US

IV. Provider business mailing address

1120 OAK DR
ELIZABETHTOWN KY
42701-2725
US

V. Phone/Fax

Practice location:
  • Phone: 661-733-9964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19591
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: