Healthcare Provider Details

I. General information

NPI: 1194885228
Provider Name (Legal Business Name): JASON MICHAEL KUSIC LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 WASHINGTON PIKE
WELLSBURG WV
26070-1962
US

IV. Provider business mailing address

494 WASHINGTON PIKE
WELLSBURG WV
26070-1962
US

V. Phone/Fax

Practice location:
  • Phone: 304-737-0925
  • Fax: 304-737-0925
Mailing address:
  • Phone: 304-737-0925
  • Fax: 304-737-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW125329
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: