MEDICARE: MR. RODNEY ROUSSETT LPC

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	101YP2500X	Professional Counselor	16771	TX

General Provider Information

NPI Number	:	1669541579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RODNEY ROUSSETT LPC

Provider Business Mailing Address
First Line	:	6800 PARK TEN BLVD STE 262-SOUTH
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-4211
Country	:	US
Telephone Number	:	210-393-1882
Fax Number	:	210-495-6049

Provider Business Practice Location Address
First Line	:	6800 PARK TEN BLVD STE 262-SOUTH
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-4211
Country	:	US
Telephone Number	:	210-393-1882
Fax Number	:	210-495-6049

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/09/2007

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