Healthcare Provider Details

I. General information

NPI: 1326457029
Provider Name (Legal Business Name): DANIEL CLAYTON COUSINS L.C.D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 RICHVALE LN
HOUSTON TX
77062-4223
US

IV. Provider business mailing address

702 RICHVALE LN
HOUSTON TX
77062-4223
US

V. Phone/Fax

Practice location:
  • Phone: 832-580-7871
  • Fax:
Mailing address:
  • Phone: 832-580-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10496
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: