Healthcare Provider Details

I. General information

NPI: 1952853004
Provider Name (Legal Business Name): NICOLE COUSINS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CENTER PLACE DEPARTMENT OF OUTPATIENT PSYCHIATRY
BOSTON MA
02118-0211
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119-2525
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5245
  • Fax: 617-414-5520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121660
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: