Provider Demographics
NPI:1417601097
Name:BRADHAM-COUSAR, MICHELLE (PHD, CRC, LMHC, NCC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:BRADHAM-COUSAR
Suffix:
Gender:F
Credentials:PHD, CRC, LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10121 E ADAMO DR UNIT 89761
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33689-9038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1503 S US 301 UNIT 92
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619
Practice Address - Country:US
Practice Address - Phone:941-250-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X, 172V00000X
FL00102595225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty