Healthcare Provider Details

I. General information

NPI: 1255796058
Provider Name (Legal Business Name): AMANDA ROUSSE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 LAURA DR STE D
THIBODAUX LA
70301-2988
US

IV. Provider business mailing address

138 FAMILY FARM RD
LOCKPORT LA
70374-4281
US

V. Phone/Fax

Practice location:
  • Phone: 985-446-4114
  • Fax:
Mailing address:
  • Phone: 985-637-2903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5293
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: