Provider Demographics
NPI:1407410582
Name:ROUGEAU, AMANDA ROSE (MT-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:ROUGEAU
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W CHESTER PIKE APT M28
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-5092
Mailing Address - Country:US
Mailing Address - Phone:732-947-6992
Mailing Address - Fax:
Practice Address - Street 1:1100 W CHESTER PIKE APT M28
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-5092
Practice Address - Country:US
Practice Address - Phone:732-947-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA14893225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist