MEDICARE: BEVERLY CUSICK PHYSICAL THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	4332	CO

General Provider Information

NPI Number	:	1679538227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY CUSICK PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	305 SOCIETY DR
Second Line	:	C-3
City	:	TELLURIDE
State	:	CO
Zip	:	81435-8936
Country	:	US
Telephone Number	:	970-728-7078
Fax Number	:	970-728-7028

Provider Business Practice Location Address
First Line	:	305 SOCIETY DR
Second Line	:	C-3
City	:	TELLURIDE
State	:	CO
Zip	:	81435-8936
Country	:	US
Telephone Number	:	970-728-7078
Fax Number	:	970-728-7028

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	07/08/2007

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