Healthcare Provider Details

I. General information

NPI: 1427366541
Provider Name (Legal Business Name): LISA MARIE COUSINEAU OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 BROCKLEY RD
ROCHESTER NY
14609-5731
US

IV. Provider business mailing address

41 OCONNOR RD
FAIRPORT NY
14450-1327
US

V. Phone/Fax

Practice location:
  • Phone: 585-256-1950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number011561-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: