Provider Demographics
NPI:1346296381
Name:COUSINEAU, TARA MCKEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:MCKEE
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-2313
Mailing Address - Country:US
Mailing Address - Phone:617-333-0630
Mailing Address - Fax:
Practice Address - Street 1:130 2ND AVE
Practice Address - Street 2:BOSTON IVF - DOMAR CENTER
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1100
Practice Address - Country:US
Practice Address - Phone:781-434-6578
Practice Address - Fax:781-370-2330
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7312103TB0200X, 103TC0700X, 103TH0100X, 103TC1900X, 103TF0000X, 103TP2701X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW-50290Medicare ID - Type Unspecified