Healthcare Provider Details

I. General information

NPI: 1568988392
Provider Name (Legal Business Name): MICHEL LEVIN ROUSSEAU MSW, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 WAYZATA BLVD STE 400
MINNETONKA MN
55305-1821
US

IV. Provider business mailing address

5905 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4463
US

V. Phone/Fax

Practice location:
  • Phone: 952-546-0616
  • Fax: 952-593-1778
Mailing address:
  • Phone: 952-546-0616
  • Fax: 952-593-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number23489
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: