Provider Demographics
NPI:1013417245
Name:COUSIN, MELONIE LEE (SLP)
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:LEE
Last Name:COUSIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 JOSLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-1004
Mailing Address - Country:US
Mailing Address - Phone:518-821-0096
Mailing Address - Fax:
Practice Address - Street 1:1 RAPP RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-4491
Practice Address - Country:US
Practice Address - Phone:518-867-3061
Practice Address - Fax:518-867-3061
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005121-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist