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General NPI Number Information
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NPI Number | 1053456525
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Entity Type | Organization
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Legal Business Name | DR. M. ROUSSEAU, PLLC
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 732 HOLLAND AVE
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City | PORT HURON
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State | MI
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Zip | 48060-1512
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Country | US
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Telephone | 810-434-6280
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Fax |
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Provider Business Mailing Address
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Address Line | 3560 PINE GROVE AVE # 613
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City | PORT HURON
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State | MI
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Zip | 48060-1994
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Country | US
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Telephone | 810-956-4389
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. MICHELLE M ROUSSEAU
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Credential | PSY.D.
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Telephone | 810-956-4389
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6301012660
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License Number State | MI
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