Provider Demographics
NPI:1790021418
Name:ROUSE, IDA LOUISE
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:LOUISE
Last Name:ROUSE
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 1:153 BRIGHTON HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-0527
Mailing Address - Country:US
Mailing Address - Phone:702-461-4403
Mailing Address - Fax:702-446-0087
Practice Address - Street 1:2755 E DESERT INN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121
Practice Address - Country:US
Practice Address - Phone:702-461-4403
Practice Address - Fax:702-446-0087
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician