Provider Demographics
NPI:1144629072
Name:ROUSE, BOBBY SR (PHD)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:ROUSE
Suffix:SR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 N STAR DR STE C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6657
Mailing Address - Country:US
Mailing Address - Phone:731-664-7949
Mailing Address - Fax:
Practice Address - Street 1:5152 SEQUOIA RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-2123
Practice Address - Country:US
Practice Address - Phone:901-351-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN335103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service