Provider Demographics
NPI:1649299801
Name:ROUSSEAU, PAUL WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WILLIAM
Last Name:ROUSSEAU
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081-7363
Mailing Address - Country:US
Mailing Address - Phone:505-824-0546
Mailing Address - Fax:
Practice Address - Street 1:5001 N PIEDRAS ST
Practice Address - Street 2:VA HEALTH CARE SYSTEM
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-4210
Practice Address - Country:US
Practice Address - Phone:915-564-6159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical