Provider Demographics
NPI:1083937262
Name:ROUSSEAU, MELISSA ANN (MACL)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:MACL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 1/2 W WILSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1825
Mailing Address - Country:US
Mailing Address - Phone:606-647-4450
Mailing Address - Fax:
Practice Address - Street 1:555 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-1612
Practice Address - Country:US
Practice Address - Phone:310-352-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF61092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist