Provider Demographics
NPI:1992820104
Name:ROUSAN, AVON LYNN (LPC)
Entity type:Individual
Prefix:MRS
First Name:AVON
Middle Name:LYNN
Last Name:ROUSAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 EDGEWATER POINTE
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2908
Mailing Address - Country:US
Mailing Address - Phone:636-561-5511
Mailing Address - Fax:636-561-5537
Practice Address - Street 1:1306 EDGEWATER POINTE
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2908
Practice Address - Country:US
Practice Address - Phone:636-561-5511
Practice Address - Fax:636-561-5537
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002534101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional