Provider Demographics
NPI:1952813412
Name:ROUSSEAU, MADELINE (LCPC, LMT)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:LCPC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11224 W CARTRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-3705
Mailing Address - Country:US
Mailing Address - Phone:503-423-7954
Mailing Address - Fax:
Practice Address - Street 1:11224 W CARTRIDGE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-3705
Practice Address - Country:US
Practice Address - Phone:503-423-7954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-9511101YM0800X
ID8158101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9511OtherIDAHO BOARD OF COUNSELORS
IDLPC-8158OtherIDAHO BOARD OF COUNSELORS