Provider Demographics
NPI:1144959578
Name:CARUSONE, JUSTINE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:CARUSONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FORT PLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:13339-1313
Mailing Address - Country:US
Mailing Address - Phone:518-268-0421
Mailing Address - Fax:
Practice Address - Street 1:14 DIVISION ST
Practice Address - Street 2:
Practice Address - City:FORT PLAIN
Practice Address - State:NY
Practice Address - Zip Code:13339-1313
Practice Address - Country:US
Practice Address - Phone:518-268-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1597292221405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional