Provider Demographics
NPI:1043254873
Name:CUSSON, SHAWN E (LATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:E
Last Name:CUSSON
Suffix:
Gender:M
Credentials:LATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 COMMONWEALTH AVE
Mailing Address - Street 2:#1001
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-2496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 BABCOCK ST
Practice Address - Street 2:BOSTON UNIVERSITY SPORTS MEDICINE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1003
Practice Address - Country:US
Practice Address - Phone:508-740-0609
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer