Provider Demographics
NPI:1366408163
Name:CUSA, NICOLE (MPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CUSA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-373-2919
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:674 UNIONVILLE RD
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-4712
Practice Address - Country:US
Practice Address - Phone:610-925-4856
Practice Address - Fax:610-925-4859
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21228225100000X
PAPT024292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189NN588Medicare PIN