Provider Demographics
NPI:1407505092
Name:ROUSSEAU, RYAN MARK
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MARK
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19611 APPLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-8074
Mailing Address - Country:US
Mailing Address - Phone:720-751-6089
Mailing Address - Fax:
Practice Address - Street 1:7220 W JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2015
Practice Address - Country:US
Practice Address - Phone:303-225-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician