MEDICARE: EMILY CUSHMAN

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1912579384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY CUSHMAN

Provider Business Mailing Address
First Line	:	PO BOX 3365
Second Line	:
City	:	CENTRAL POINT
State	:	OR
Zip	:	97502-0014
Country	:	US
Telephone Number	:	541-727-1592
Fax Number	:

Provider Business Practice Location Address
First Line	:	2368 CRATER LAKE AVE STE 102
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-5006
Country	:	US
Telephone Number	:	541-727-1592
Fax Number	:

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	07/14/2021

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Directions to “ EMILY CUSHMAN ” Practice Location

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