Provider Demographics
NPI:1568238558
Name:DEROUSSE, MADISON (PLPC)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:DEROUSSE
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 N CLAY AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4068
Mailing Address - Country:US
Mailing Address - Phone:573-880-6536
Mailing Address - Fax:
Practice Address - Street 1:214 CLAY STREET
Practice Address - Street 2:SUITE 215
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122
Practice Address - Country:US
Practice Address - Phone:573-880-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024014799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health