1669849717 NPI number — ALENA COUSINS

Table of content: ALENA COUSINS (NPI 1669849717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669849717 NPI number — ALENA COUSINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUSINS
Provider First Name:
ALENA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIS
Provider Other First Name:
ALENA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669849717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1303 W 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45504-1920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-717-4045
Provider Business Mailing Address Fax Number:
937-717-4811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 W 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45504-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-717-4045
Provider Business Practice Location Address Fax Number:
937-717-4811
Provider Enumeration Date:
08/25/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3254 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT 016062 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H2090800 . This is a "MEDICAID GROUP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".