Healthcare Provider Details

I. General information

NPI: 1215693296
Provider Name (Legal Business Name): KERRIE ROUSE PHD, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2021
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 HOLLY AVE STE 8
WINSTON SALEM NC
27101-2716
US

IV. Provider business mailing address

632 HOLLY AVE STE 8
WINSTON SALEM NC
27101-2716
US

V. Phone/Fax

Practice location:
  • Phone: 512-355-1091
  • Fax:
Mailing address:
  • Phone: 512-355-1091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number21126
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number204231
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-6741
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberTPMC2976
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number87503
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: