MEDICARE: LISA ROUSSO RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	004833	NY

General Provider Information

NPI Number	:	1235385618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ROUSSO RD

Provider Business Mailing Address
First Line	:	110-11 QUEENS BLVD #9-D
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6551
Country	:	US
Telephone Number	:	646-229-5575
Fax Number	:

Provider Business Practice Location Address
First Line	:	11420 ROCKAWAY BLVD
Second Line	:
City	:	SOUTH OZONE PARK
State	:	NY
Zip	:	11420-1912
Country	:	US
Telephone Number	:	646-229-5575
Fax Number	:	917-300-2125

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2008
Last Update Date	:	10/05/2015

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Directions to “ LISA ROUSSO RD” Practice Location

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