Provider Demographics
NPI:1790771632
Name:ROULEAU, SUZANNE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:M
Last Name:ROULEAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BLUE JAY DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-1210
Mailing Address - Country:US
Mailing Address - Phone:302-479-5157
Mailing Address - Fax:302-300-1337
Practice Address - Street 1:1601 MILLTOWN RD
Practice Address - Street 2:STE 8
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-4073
Practice Address - Country:US
Practice Address - Phone:302-479-5157
Practice Address - Fax:302-300-1337
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-00006771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000025889Medicaid
DE019443T28Medicare ID - Type UnspecifiedPROVIDER NUMBER