Provider Demographics
NPI:1255475687
Name:ROUSSOS, ANDREA H (PT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:H
Last Name:ROUSSOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 LOS ANGELES BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1647
Mailing Address - Country:US
Mailing Address - Phone:141-525-9028
Mailing Address - Fax:
Practice Address - Street 1:180 LOS ANGELES BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1647
Practice Address - Country:US
Practice Address - Phone:141-525-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist