Provider Demographics
NPI:1982874889
Name:COUSINS, GLORIA
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
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 1:22900 REMICK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2732
Mailing Address - Country:US
Mailing Address - Phone:586-783-4802
Mailing Address - Fax:586-783-4805
Practice Address - Street 1:2520 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3312
Practice Address - Country:US
Practice Address - Phone:248-706-5041
Practice Address - Fax:248-706-5046
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-00016101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)