Healthcare Provider Details

I. General information

NPI: 1730281155
Provider Name (Legal Business Name): NICHOLAS ROUSIS ROUSIS M.ED., M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 PRUDENTIAL DR SUITE 1350
JACKSONVILLE FL
32207-8147
US

IV. Provider business mailing address

PO BOX 44231
JACKSONVILLE FL
32231-4231
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-3800
  • Fax: 904-396-8966
Mailing address:
  • Phone: 904-376-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS329
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW6140
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: