Provider Demographics
NPI:1114260437
Name:COUSIN, GREGORY JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:COUSIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8118 TAR HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3023
Mailing Address - Country:US
Mailing Address - Phone:813-900-0070
Mailing Address - Fax:
Practice Address - Street 1:8118 TAR HOLLOW DR
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3023
Practice Address - Country:US
Practice Address - Phone:813-900-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 66227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist