Provider Demographics
NPI:1235385618
Name:ROUSSO, LISA (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROUSSO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110-11 QUEENS BLVD #9-D
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6551
Mailing Address - Country:US
Mailing Address - Phone:646-229-5575
Mailing Address - Fax:
Practice Address - Street 1:11420 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1912
Practice Address - Country:US
Practice Address - Phone:646-229-5575
Practice Address - Fax:917-300-2125
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-17
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004833133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered