Provider Demographics
NPI:1962755660
Name:ROUSE, KRISTYN TECCA (LPC)
Entity type:Individual
Prefix:MRS
First Name:KRISTYN
Middle Name:TECCA
Last Name:ROUSE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRISYN
Other - Middle Name:ROUSE
Other - Last Name:FUNKHOUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:100 WESTSIDE DR.
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-793-2237
Mailing Address - Fax:334-712-6256
Practice Address - Street 1:100 WESTSIDE DR.
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303
Practice Address - Country:US
Practice Address - Phone:334-793-2237
Practice Address - Fax:334-712-6256
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2041A101YM0800X
AL3323101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health