1073007415 NPI number — EDIE M SOUZA BEHAVIORAL THERAPIST

Table of content: EDIE M SOUZA BEHAVIORAL THERAPIST (NPI 1073007415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073007415 NPI number — EDIE M SOUZA BEHAVIORAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUZA
Provider First Name:
EDIE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BEHAVIORAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073007415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11037 WARNER AVE # 339
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOUNTAIN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92708-4007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-273-4292
Provider Business Mailing Address Fax Number:
888-293-3374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2752 WOODLAWN DR STE 5-202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96822-1855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-273-4292
Provider Business Practice Location Address Fax Number:
888-293-3374
Provider Enumeration Date:
06/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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