Provider Demographics
NPI:1407847387
Name:COUSINEAU, AMY LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LYNN
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:HOUSER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2040 AURELIUS RD STE 20
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1367
Mailing Address - Country:US
Mailing Address - Phone:517-699-3937
Mailing Address - Fax:517-699-4199
Practice Address - Street 1:2040 AURELIUS RD STE 20
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842
Practice Address - Country:US
Practice Address - Phone:517-699-3937
Practice Address - Fax:517-699-4199
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU88630Medicare UPIN
P07240002Medicare ID - Type Unspecified