Provider Demographics
NPI:1538344460
Name:ROUSSEAU, ELIZABETH L (MA, MT-BC, QMHP)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:L
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:MA, MT-BC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 SE 56TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6874
Mailing Address - Country:US
Mailing Address - Phone:971-404-5982
Mailing Address - Fax:
Practice Address - Street 1:6021 SE 56TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6874
Practice Address - Country:US
Practice Address - Phone:971-404-5982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
101Y00000X, 225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor