Provider Demographics
NPI:1104177047
Name:COUSINEAU, RANDY LEROY (CAADC, LPC, MLSW)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LEROY
Last Name:COUSINEAU
Suffix:
Gender:M
Credentials:CAADC, LPC, MLSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 COMMERCE ST.
Mailing Address - Street 2:WEST MICHIGAN THERAPY
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441
Mailing Address - Country:US
Mailing Address - Phone:231-728-2138
Mailing Address - Fax:231-722-4771
Practice Address - Street 1:1823 COMMERCE ST.
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49411
Practice Address - Country:US
Practice Address - Phone:231-728-2138
Practice Address - Fax:231-722-4771
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001535101Y00000X
MI206486101YA0400X
MI6801057570104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker