Healthcare Provider Details

I. General information

NPI: 1669664199
Provider Name (Legal Business Name): DR. JOHN THOMAS ROUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN THOMAS ROUSE PH.D.

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 BROADWAY, SUITE 835
OAKLAND CA
94612
US

IV. Provider business mailing address

1970 BROADWAY, SUITE 835
OAKLAND CA
94612
US

V. Phone/Fax

Practice location:
  • Phone: 510-452-2220
  • Fax: 916-993-6428
Mailing address:
  • Phone: 510-452-2220
  • Fax: 916-993-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY11264
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY11264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: