Provider Demographics
NPI:1497853261
Name:SMITH, DOREEN ROUSSEAU (LPC LIC PROF COUNS)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:ROUSSEAU
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC LIC PROF COUNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NORTHFIELD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-3321
Mailing Address - Country:US
Mailing Address - Phone:860-561-0489
Mailing Address - Fax:860-561-0489
Practice Address - Street 1:90 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1924
Practice Address - Country:US
Practice Address - Phone:860-983-7507
Practice Address - Fax:860-561-0489
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000109101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000109OtherPROFESSIONAL LICENSE