Healthcare Provider Details

I. General information

NPI: 1902110737
Provider Name (Legal Business Name): MICHAELLE DESRUISSEAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 KOALA DR
KISSIMMEE FL
34759-4210
US

IV. Provider business mailing address

570 KOALA DR
KISSIMMEE FL
34759-4210
US

V. Phone/Fax

Practice location:
  • Phone: 407-285-5626
  • Fax:
Mailing address:
  • Phone: 407-285-5626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW20097
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200003082
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: