Provider Demographics
NPI:1467802355
Name:ROUSSOS, SUSAN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:ROUSSOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 SANFORD CIR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4924
Mailing Address - Country:US
Mailing Address - Phone:970-278-9079
Mailing Address - Fax:
Practice Address - Street 1:2980 SANFORD CIR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4924
Practice Address - Country:US
Practice Address - Phone:970-278-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72023881251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services