Provider Demographics
NPI:1811062029
Name:ROUSSEAU, RUDOLPH
Entity type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:
Last Name:ROUSSEAU
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 1:5933 29TH PL N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 CONCORDIA AVE
Practice Address - Street 2:STE 1100
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2443
Practice Address - Country:US
Practice Address - Phone:651-325-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1420103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113090OtherUCAREBHP
MN1G284ROMedicare UPIN
MN6265847Medicare UPIN
MNHP18914Medicare UPIN
MN113090OtherUCAREBHP