Provider Demographics
NPI:1093966384
Name:ROUSSEAU, KATHLEEN ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CARLISLE RD
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1906
Mailing Address - Country:US
Mailing Address - Phone:631-473-0943
Mailing Address - Fax:
Practice Address - Street 1:16 CARLISLE RD
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-1906
Practice Address - Country:US
Practice Address - Phone:631-473-0943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-04
Last Update Date:2008-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004811-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist