Basic Information
| Provider Information | |||||||||
| NPI: | 1457870297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROUSELLE | ||||||||
| FirstName: | DENITA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 913 S COLLEGE RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705033061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375348433 | ||||||||
| FaxNumber: | 3375348428 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 REES ST, | ||||||||
| Address2: | |||||||||
| City: | BREAUX BRIDGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374426823 | ||||||||
| FaxNumber: | 3374426825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.