MEDICARE: RUDOLPH ROUSSEAU

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	103T00000X	Psychologist	1420	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	113090	OTHER	MN	UCAREBHP

General Provider Information

NPI Number	:	1811062029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUDOLPH ROUSSEAU

Provider Business Mailing Address
First Line	:	5933 29TH PL N
Second Line	:
City	:	CRYSTAL
State	:	MN
Zip	:	55422-2559
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	560 CONCORDIA AVE
Second Line	:	STE 1100
City	:	SAINT PAUL
State	:	MN
Zip	:	55103-2443
Country	:	US
Telephone Number	:	651-325-2766
Fax Number	:

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

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/09/2007

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Directions to “ RUDOLPH ROUSSEAU ” Practice Location

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