Provider Demographics
NPI:1750842555
Name:ROUSE, SHANNON KATHERINE (LMFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHERINE
Last Name:ROUSE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:75 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1917
Mailing Address - Country:US
Mailing Address - Phone:203-554-4054
Mailing Address - Fax:
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2718
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2035106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist