Provider Demographics
NPI:1447480868
Name:COSSE, TED (MA)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:COSSE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:THEOPOLIS
Other - Middle Name:
Other - Last Name:COSSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:155 S DE LACEY AVE
Mailing Address - Street 2:APARTMENT 1004
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-4521
Mailing Address - Country:US
Mailing Address - Phone:818-939-3280
Mailing Address - Fax:
Practice Address - Street 1:180 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1714
Practice Address - Country:US
Practice Address - Phone:626-584-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26226103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist