MEDICARE: DOREEN ROUSSEAU SMITH LPC LIC PROF COUNS

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	101Y00000X	Counselor	000109	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000109	OTHER	CT	PROFESSIONAL LICENSE

General Provider Information

NPI Number	:	1497853261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOREEN ROUSSEAU SMITH LPC LIC PROF COUNS

Provider Business Mailing Address
First Line	:	10 NORTHFIELD
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-3321
Country	:	US
Telephone Number	:	860-561-0489
Fax Number	:	860-561-0489

Provider Business Practice Location Address
First Line	:	90 N MAIN ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-1924
Country	:	US
Telephone Number	:	860-983-7507
Fax Number	:	860-561-0489

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/13/2007

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