MEDICARE: KELLI COUSLER MCD, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	6458	LA

General Provider Information

NPI Number	:	1205254802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI COUSLER MCD, CCC-SLP

Provider Business Mailing Address
First Line	:	5017 TENSAS DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2537
Country	:	US
Telephone Number	:	504-417-0404
Fax Number	:

Provider Business Practice Location Address
First Line	:	5017 TENSAS DR
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2537
Country	:	US
Telephone Number	:	504-417-0404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2014
Last Update Date	:	04/01/2014

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Directions to “ KELLI COUSLER MCD, CCC-SLP” Practice Location

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