=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639232804
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY MARIE CUSACK M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 12/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 COON RAPIDS BLVD NW STE 200 SUITE 100
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-784-3008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4023 24TH AVE S
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55406-3023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-823-6578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LP 3907
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------