Provider Demographics
NPI:1568983492
Name:ROUILLARD, HEATHER (LMFT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:ROUILLARD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12531 71ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:MOTLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56466-2510
Mailing Address - Country:US
Mailing Address - Phone:612-702-2456
Mailing Address - Fax:
Practice Address - Street 1:12531 71ST AVE SW
Practice Address - Street 2:
Practice Address - City:MOTLEY
Practice Address - State:MN
Practice Address - Zip Code:56466-2510
Practice Address - Country:US
Practice Address - Phone:612-702-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3736106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health