Provider Demographics
NPI:1912359589
Name:ROUSSEAU, MARYSA
Entity Type:Individual
Prefix:
First Name:MARYSA
Middle Name:
Last Name:ROUSSEAU
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 1:145 ROSEMARY ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM HEIGHTS
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3238
Mailing Address - Country:US
Mailing Address - Phone:317-815-5501
Mailing Address - Fax:317-815-3861
Practice Address - Street 1:1025 E 54TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3219
Practice Address - Country:US
Practice Address - Phone:317-815-5501
Practice Address - Fax:317-815-3861
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst