Basic Information
| Provider Information | |||||||||
| NPI: | 1891248175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUSSAN | ||||||||
| FirstName: | DIANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376939798 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 MACARTHUR DR | ||||||||
| Address2: | |||||||||
| City: | SUNSET | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705846212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376623737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2016 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.