Provider Demographics
NPI:1376606913
Name:COUSENS, TED STEWART (MFT)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:STEWART
Last Name:COUSENS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150540
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94915-0540
Mailing Address - Country:US
Mailing Address - Phone:415-289-2221
Mailing Address - Fax:
Practice Address - Street 1:130 GREENFIELD AVE STE A
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2451
Practice Address - Country:US
Practice Address - Phone:415-289-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 39070106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist