Healthcare Provider Details

I. General information

NPI: 1760393706
Provider Name (Legal Business Name): GELISSA COUSLEY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 N STATE ROAD 7 STE 409D
LAUDERDALE LAKES FL
33319-4882
US

IV. Provider business mailing address

4000 N STATE ROAD 7 STE 409D
LAUDERDALE LAKES FL
33319-4882
US

V. Phone/Fax

Practice location:
  • Phone: 954-508-9180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF408753-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11043643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: