MEDICARE: MS. KELLIE RENEE COUSINO LISW

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	1041C0700X	Clinical Social Worker	15180	SC
2	1041C0700X	Clinical Social Worker	I.2203507-SUPV	OH
3	1041C0700X	Clinical Social Worker	21506	FL

General Provider Information

NPI Number	:	1295224897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLIE RENEE COUSINO LISW

Provider Business Mailing Address
First Line	:	2606 102ND ST
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43611-2010
Country	:	US
Telephone Number	:	419-217-2122
Fax Number	:

Provider Business Practice Location Address
First Line	:	2606 102ND ST
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43611-2010
Country	:	US
Telephone Number	:	419-217-2122
Fax Number	:

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

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	03/18/2026

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