Basic Information
| Provider Information | |||||||||
| NPI: | 1396044459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUSSELLE | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 BRYANT WOODS S | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142283604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013137770 | ||||||||
| FaxNumber: | 8013137771 | ||||||||
| Practice Location | |||||||||
| Address1: | 5770 S 1500 W | ||||||||
| Address2: | BUILDING G | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013137770 | ||||||||
| FaxNumber: | 8013137771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2011 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 7893436-2501 | UT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.