Provider Demographics
NPI:1073155982
Name:ROUSE, IMANI N (LCDC INTERN)
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:N
Last Name:ROUSE
Suffix:
Gender:F
Credentials:LCDC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3291
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-0291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6406 HIGHWAY 78 STE 108
Practice Address - Street 2:
Practice Address - City:SACHSE
Practice Address - State:TX
Practice Address - Zip Code:75048-3276
Practice Address - Country:US
Practice Address - Phone:469-584-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YA0400X
TX107100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000OtherCASH PAY