Provider Demographics
NPI:1578298055
Name:ROUSSIN, ALICIA M (DR)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:ROUSSIN
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 COPPER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1301
Mailing Address - Country:US
Mailing Address - Phone:505-268-7988
Mailing Address - Fax:505-268-8021
Practice Address - Street 1:5006 COPPER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1301
Practice Address - Country:US
Practice Address - Phone:505-268-7988
Practice Address - Fax:505-268-8021
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT61522251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics