Provider Demographics
NPI:1629191432
Name:COUSINS, PHILADELPHIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PHILADELPHIA
Middle Name:
Last Name:COUSINS
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 1:4251 KIPLING ST
Mailing Address - Street 2:345
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2896
Mailing Address - Country:US
Mailing Address - Phone:303-421-3811
Mailing Address - Fax:
Practice Address - Street 1:4251 KIPLING ST
Practice Address - Street 2:SUITE 345
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2896
Practice Address - Country:US
Practice Address - Phone:303-421-3811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1051103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89996OtherBLUE CROSS BLUE SHIELD ID