Provider Demographics
NPI:1760721815
Name:COUSINS, ANGELLA
Entity Type:Individual
Prefix:
First Name:ANGELLA
Middle Name:
Last Name:COUSINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 WALDEN RUN PL
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7011
Mailing Address - Country:US
Mailing Address - Phone:678-651-4495
Mailing Address - Fax:
Practice Address - Street 1:708 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-2720
Practice Address - Country:US
Practice Address - Phone:770-833-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-10
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator