Provider Demographics
NPI:1679757231
Name:CUSACK, KATHERINE SOPHIE (PT)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:SOPHIE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:SOPHIE
Other - Last Name:DUSIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4006 CAMROSE CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6831
Mailing Address - Country:US
Mailing Address - Phone:224-392-4872
Mailing Address - Fax:
Practice Address - Street 1:5960 FAIRVIEW RD
Practice Address - Street 2:SUITE 250
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3102
Practice Address - Country:US
Practice Address - Phone:980-224-7958
Practice Address - Fax:980-224-7973
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0397730007Medicare NSC