Provider Demographics
NPI:1518218767
Name:ROUSSEAU, EMILY FERRIS (LCSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:FERRIS
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 S DIANA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3226
Mailing Address - Country:US
Mailing Address - Phone:435-209-0063
Mailing Address - Fax:
Practice Address - Street 1:1950 CIRCLE OF HOPE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5500
Practice Address - Country:US
Practice Address - Phone:435-209-0063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8949498-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical