Provider Demographics
NPI:1811663263
Name:COUSIN, BRANNON TYSHAUN
Entity type:Individual
Prefix:
First Name:BRANNON
Middle Name:TYSHAUN
Last Name:COUSIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3654
Mailing Address - Country:US
Mailing Address - Phone:605-454-7910
Mailing Address - Fax:
Practice Address - Street 1:28 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3654
Practice Address - Country:US
Practice Address - Phone:605-454-7910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer