Provider Demographics
NPI:1780118612
Name:COUSINEAU, TARA (BA)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:PO BOX 1202
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-1202
Mailing Address - Country:US
Mailing Address - Phone:253-255-1567
Mailing Address - Fax:
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8330
Practice Address - Country:US
Practice Address - Phone:360-373-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor