Provider Demographics
NPI:1417494345
Name:ROUSE, MARLO T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARLO
Middle Name:T
Last Name:ROUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 CLAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4004
Mailing Address - Country:US
Mailing Address - Phone:912-541-0025
Mailing Address - Fax:
Practice Address - Street 1:1800 PHOENIX BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5593
Practice Address - Country:US
Practice Address - Phone:770-996-6664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000995106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist