Provider Demographics
NPI:1871477950
Name:CUSACK, MICHAEL JOHN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:CUSACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9255 NE ROCKSPRING ST APT B222
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29781 SW TOWN CENTER LOOP W STE 200
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-8902
Practice Address - Country:US
Practice Address - Phone:503-946-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-02
Last Update Date:2025-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18602235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist