Provider Demographics
NPI:1689039554
Name:CUSIMANO, CARLA (MA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:CUSIMANO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 REMSEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-1017
Practice Address - Country:US
Practice Address - Phone:718-495-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist