Provider Demographics
NPI:1386137107
Name:COUSINEAU, REBECCA (LMT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RAILROAD ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WARNERS
Mailing Address - State:NY
Mailing Address - Zip Code:13164-9730
Mailing Address - Country:US
Mailing Address - Phone:315-350-0715
Mailing Address - Fax:
Practice Address - Street 1:4464 MILTON AVE
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1287
Practice Address - Country:US
Practice Address - Phone:315-350-0715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist