Healthcare Provider Details

I. General information

NPI: 1033742903
Provider Name (Legal Business Name): SHAWN DIMITRI ROUSE CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 MUDDY CREEK RD
CINCINNATI OH
45238-2057
US

IV. Provider business mailing address

5665 MONTGOMERY RD
CINCINNATI OH
45212-1821
US

V. Phone/Fax

Practice location:
  • Phone: 513-347-0375
  • Fax:
Mailing address:
  • Phone: 203-407-9825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA186118
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: