MEDICARE: THERESA LYNN ROUSH MS THERAPIST

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist
3	103TB0200X	Cognitive & Behavioral Psychologist
4	103TC1900X	Counseling Psychologist
5	103TC2200X	Clinical Child & Adolescent Psychologist

General Provider Information

NPI Number	:	1972359420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA LYNN ROUSH MS THERAPIST

Provider Business Mailing Address
First Line	:	1498 WILLIAM ST APT 2
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-3891
Country	:	US
Telephone Number	:	480-363-5176
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 W MAIN ST
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-5148
Country	:	US
Telephone Number	:	352-842-9590
Fax Number	:

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

Provider Enumeration Date	:	04/25/2024
Last Update Date	:	04/25/2024

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