Provider Demographics
NPI:1144077306
Name:CUSACK, CHRISTINE (LCSW, BCBA)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:CUSACK
Suffix:
Gender:F
Credentials:LCSW, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 S FINLEY RD APT 112
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6451
Mailing Address - Country:US
Mailing Address - Phone:312-859-5357
Mailing Address - Fax:
Practice Address - Street 1:422 S MAIN ST UNIT 2040
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2600
Practice Address - Country:US
Practice Address - Phone:630-791-0995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-22-58906103K00000X
IL149.0184211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst