Provider Demographics
NPI:1083302319
Name:COUSIN, DAMON JR
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:COUSIN
Suffix:JR
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 1:820 ASBURY DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-1842
Mailing Address - Country:US
Mailing Address - Phone:985-674-5155
Mailing Address - Fax:985-674-5156
Practice Address - Street 1:820 ASBURY DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-1842
Practice Address - Country:US
Practice Address - Phone:985-674-5155
Practice Address - Fax:985-674-5156
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA17226104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator