Provider Demographics
NPI:1902046220
Name:DESOUZA, THERESA M (CAS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:DESOUZA
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 JULIESSE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-1803
Mailing Address - Country:US
Mailing Address - Phone:916-609-4821
Mailing Address - Fax:916-921-6604
Practice Address - Street 1:1550 JULIESSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-1803
Practice Address - Country:US
Practice Address - Phone:916-609-4821
Practice Address - Fax:916-921-6604
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-080650324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-080650OtherCOUNSELOR