Provider Demographics
NPI:1316764335
Name:COUSINS, TYA
Entity type:Individual
Prefix:
First Name:TYA
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 1:1130 14TH ST APT 255B
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4062
Mailing Address - Country:US
Mailing Address - Phone:304-982-9859
Mailing Address - Fax:
Practice Address - Street 1:1130 14TH ST APT 255B
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-4062
Practice Address - Country:US
Practice Address - Phone:304-982-9859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYI16790390200000X
OH060005176390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program