Provider Demographics
NPI:1639372097
Name:ROUSH, NATASHA NICOLE
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:NICOLE
Last Name:ROUSH
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 1:3050 W STONERIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-0753
Mailing Address - Country:US
Mailing Address - Phone:304-654-1369
Mailing Address - Fax:
Practice Address - Street 1:1171 S KGB RD
Practice Address - Street 2:STE 700
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:304-736-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00941482104100000X
AK13361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker