Basic Information
| Provider Information | |||||||||
| NPI: | 1679825012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUSKA | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 SW SALIX TER | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970063522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415711165 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1904 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972021146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035178663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | OR | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.