Healthcare Provider Details

I. General information

NPI: 1053456525
Provider Name (Legal Business Name): DR. M. ROUSSEAU, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HOLLAND AVE
PORT HURON MI
48060-1512
US

IV. Provider business mailing address

3560 PINE GROVE AVE # 613
PORT HURON MI
48060-1994
US

V. Phone/Fax

Practice location:
  • Phone: 810-434-6280
  • Fax:
Mailing address:
  • Phone: 810-956-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301012660
License Number StateMI

VIII. Authorized Official

Name: DR. MICHELLE M ROUSSEAU
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSY.D.
Phone: 810-956-4389