Provider Demographics
NPI:1801147905
Name:ROUSE, SHANDA
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:ROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 LIVONIA AVE
Mailing Address - Street 2:APARTMENT 14E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-6067
Mailing Address - Country:US
Mailing Address - Phone:917-592-5745
Mailing Address - Fax:
Practice Address - Street 1:555 REMSEN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-1017
Practice Address - Country:US
Practice Address - Phone:718-495-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist