Provider Demographics
NPI:1952882995
Name:COUSINEAU, SUSAN ANN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:COUSINEAU
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 1:3100 THORNTREE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-2479
Mailing Address - Country:US
Mailing Address - Phone:517-740-7422
Mailing Address - Fax:
Practice Address - Street 1:122 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9164
Practice Address - Country:US
Practice Address - Phone:151-774-0742
Practice Address - Fax:517-315-4918
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902003787124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist