Provider Demographics
NPI:1760782619
Name:COUSINS, DANIEL DEAN SR (MSW, CSAC, IDP-AT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:DEAN
Last Name:COUSINS
Suffix:SR
Gender:M
Credentials:MSW, CSAC, IDP-AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15617 US HIGHWAY 63
Mailing Address - Street 2:P.O. BOX 800
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-4244
Mailing Address - Country:US
Mailing Address - Phone:715-634-4673
Mailing Address - Fax:715-634-4675
Practice Address - Street 1:15617 US HIGHWAY 63
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-4244
Practice Address - Country:US
Practice Address - Phone:715-634-4673
Practice Address - Fax:715-634-4675
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15562-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)