Provider Demographics
NPI:1447302278
Name:KOUSSA, THERESE MARIE (CCC-A)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
Last Name:KOUSSA
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:THERESE
Other - Middle Name:MARIE
Other - Last Name:TUDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1615
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:25 NEEDHAM ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02461-1615
Practice Address - Country:US
Practice Address - Phone:617-964-6681
Practice Address - Fax:617-630-0141
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAUD00069231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist