Provider Demographics
NPI:1902272156
Name:COUSINEAU, TIVOLI (LMFT)
Entity Type:Individual
Prefix:
First Name:TIVOLI
Middle Name:
Last Name:COUSINEAU
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6640 OLD FOREST DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5958
Mailing Address - Country:US
Mailing Address - Phone:310-384-0086
Mailing Address - Fax:
Practice Address - Street 1:2700 HOMESTEAD RD STE 210
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4858
Practice Address - Country:US
Practice Address - Phone:310-384-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10511721-3902106H00000X
CA83685106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist