Healthcare Provider Details

I. General information

NPI: 1427831403
Provider Name (Legal Business Name): KOUSA PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 BEACON ST STE 300
BROOKLINE MA
02446-5252
US

IV. Provider business mailing address

1309 BEACON ST STE 300
BROOKLINE MA
02446-5252
US

V. Phone/Fax

Practice location:
  • Phone: 617-286-2526
  • Fax:
Mailing address:
  • Phone: 617-286-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: YUQIAN TIAN
Title or Position: MANAGER/THERAPIST
Credential: LMHC
Phone: 617-286-2526