Healthcare Provider Details

I. General information

NPI: 1235630153
Provider Name (Legal Business Name): VALERIE ANNE CUSHMAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 E GENESEE ST
SYRACUSE NY
13210-1912
US

IV. Provider business mailing address

1106 E GENESEE ST
SYRACUSE NY
13210-1912
US

V. Phone/Fax

Practice location:
  • Phone: 315-422-6828
  • Fax:
Mailing address:
  • Phone: 315-382-4619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27-P09101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: