Provider Demographics
NPI:1225791841
Name:ROUX, JOHANNES PETRUS (PHD LMFT)
Entity Type:Individual
Prefix:DR
First Name:JOHANNES
Middle Name:PETRUS
Last Name:ROUX
Suffix:
Gender:M
Credentials:PHD LMFT
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:P
Other - Last Name:ROUX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD LMFT
Mailing Address - Street 1:1 BLACKFIELD DR # 364
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2053
Mailing Address - Country:US
Mailing Address - Phone:415-272-0293
Mailing Address - Fax:
Practice Address - Street 1:310 RIVIERA CIR
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1544
Practice Address - Country:US
Practice Address - Phone:415-272-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31698101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty