Provider Demographics
NPI:1700555836
Name:KOUSHIAFES, GEORGIA FAYE (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:FAYE
Last Name:KOUSHIAFES
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W DODDS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4773
Mailing Address - Country:US
Mailing Address - Phone:812-360-2869
Mailing Address - Fax:
Practice Address - Street 1:604 W DODDS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4773
Practice Address - Country:US
Practice Address - Phone:812-360-2869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-11
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003881A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical