Healthcare Provider Details

I. General information

NPI: 1043254873
Provider Name (Legal Business Name): SHAWN E CUSSON LATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BABCOCK ST BOSTON UNIVERSITY SPORTS MEDICINE
BOSTON MA
02215-1003
US

IV. Provider business mailing address

700 COMMONWEALTH AVE #1001
BOSTON MA
02215-2496
US

V. Phone/Fax

Practice location:
  • Phone: 508-740-0609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1338
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: