Provider Demographics
NPI:1164893905
Name:ROUSSEAU, MARY (ATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 CORNELIA ST
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-1804
Mailing Address - Country:US
Mailing Address - Phone:862-579-8441
Mailing Address - Fax:
Practice Address - Street 1:423 CORNELIA ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1804
Practice Address - Country:US
Practice Address - Phone:862-579-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer