Basic Information
| Provider Information | |||||||||
| NPI: | 1326530247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUSSEAU | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | MSW, LBSW, CAADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2236 E MITCHELL RD UNIT 5 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497709604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313479880 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2236 E MITCHELL RD UNIT 5 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497709604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313479880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2018 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C-00022 | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 6802081470 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.