Provider Demographics
NPI:1881610277
Name:ROUSSEAU, MYRNA (OTR,L/ CHT)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:OTR,L/ CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1587 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1453
Mailing Address - Country:US
Mailing Address - Phone:707-441-9131
Mailing Address - Fax:707-441-1940
Practice Address - Street 1:1587 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1453
Practice Address - Country:US
Practice Address - Phone:707-441-9131
Practice Address - Fax:707-441-1940
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2554225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01534ZMedicare PIN