Provider Demographics
NPI:1548816788
Name:COUSINO, CARISSA MARIE
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:COUSINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:MARIE
Other - Last Name:ROCHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4029 SOUTHWELL DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:MI
Mailing Address - Zip Code:49269-9419
Mailing Address - Country:US
Mailing Address - Phone:734-772-7443
Mailing Address - Fax:
Practice Address - Street 1:4029 SOUTHWELL DR
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:MI
Practice Address - Zip Code:49269-9419
Practice Address - Country:US
Practice Address - Phone:734-772-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004314225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant