MEDICARE: MYRA COUSINS

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1609035732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRA COUSINS

Provider Business Mailing Address
First Line	:	432 N 6TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19123-4004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 S 4TH ST
Second Line	:	4TH FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-5907
Country	:	US
Telephone Number	:	215-339-1070
Fax Number	:

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

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	06/04/2008

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Directions to “ MYRA COUSINS ” Practice Location

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