Provider Demographics
NPI:1558033464
Name:COUSIN, DELORES A (MA)
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:A
Last Name:COUSIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-1627
Mailing Address - Country:US
Mailing Address - Phone:504-452-6466
Mailing Address - Fax:
Practice Address - Street 1:10040 I 10 SERVICE RD STE C
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-2703
Practice Address - Country:US
Practice Address - Phone:504-821-5220
Practice Address - Fax:504-821-6330
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA9447101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator