Provider Demographics
NPI:1194198267
Name:ROUSSEL, DUSTIN
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:ROUSSEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LUTCHER
Mailing Address - State:LA
Mailing Address - Zip Code:70071-5517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3939 HOUMA BLVD
Practice Address - Street 2:STE 17
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2931
Practice Address - Country:US
Practice Address - Phone:504-885-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09062R261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy