Provider Demographics
NPI:1104793132
Name:ROSEAU, MARIE LUNIQUE (LAC)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:LUNIQUE
Last Name:ROSEAU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:NIK
Other - Middle Name:
Other - Last Name:ROSEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:1904 W PARKSIDE LN STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1904 W PARKSIDE LN STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1232
Practice Address - Country:US
Practice Address - Phone:480-757-5885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-23
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22792101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health