MEDICARE: SALLY J ROUSSEAU SALLY ROUSSEAU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	73 076601	NY
2	106H00000X	Marriage & Family Therapist	000449	NY

General Provider Information

NPI Number	:	1831330257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY J ROUSSEAU SALLY ROUSSEAU

Provider Business Mailing Address
First Line	:	1381 SOUTH AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2830
Country	:	US
Telephone Number	:	585-506-9484
Fax Number	:

Provider Business Practice Location Address
First Line	:	1381 SOUTH AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-2830
Country	:	US
Telephone Number	:	585-506-9484
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2009
Last Update Date	:	03/14/2009

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Directions to “ SALLY J ROUSSEAU SALLY ROUSSEAU” Practice Location

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