Healthcare Provider Details

I. General information

NPI: 1558027904
Provider Name (Legal Business Name): TYLER H COUSINS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CANAL ST
SALEM MA
01970-4649
US

IV. Provider business mailing address

23 LITTLES POINT RD
SWAMPSCOTT MA
01907-2833
US

V. Phone/Fax

Practice location:
  • Phone: 978-744-1123
  • Fax:
Mailing address:
  • Phone: 978-223-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12211
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: