Provider Demographics
NPI:1669664199
Name:ROUSE, JOHN THOMAS
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:ROUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:THOMAS
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1970 BROADWAY, SUITE 835
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612
Mailing Address - Country:US
Mailing Address - Phone:510-452-2220
Mailing Address - Fax:916-993-6428
Practice Address - Street 1:1970 BROADWAY, SUITE 835
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612
Practice Address - Country:US
Practice Address - Phone:510-452-2220
Practice Address - Fax:916-993-6428
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11264103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic