Provider Demographics
NPI:1831330257
Name:ROUSSEAU, SALLY J (SALLY ROUSSEAU)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:SALLY ROUSSEAU
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:J
Other - Last Name:ROUSSEAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SALLY ROUSSEAU, MSW
Mailing Address - Street 1:1381 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2830
Mailing Address - Country:US
Mailing Address - Phone:585-506-9484
Mailing Address - Fax:
Practice Address - Street 1:1381 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2830
Practice Address - Country:US
Practice Address - Phone:585-506-9484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-14
Last Update Date:2009-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 0766011041C0700X
NY000449106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical