Provider Demographics
NPI:1902314164
Name:DESOUZA ADDO, ALBERTA WINNIFRED
Entity Type:Individual
Prefix:MRS
First Name:ALBERTA
Middle Name:WINNIFRED
Last Name:DESOUZA ADDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 W 132ND ST
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2484
Mailing Address - Country:US
Mailing Address - Phone:952-215-9206
Mailing Address - Fax:
Practice Address - Street 1:6220 W 132ND ST
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2484
Practice Address - Country:US
Practice Address - Phone:952-215-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1088299-1-HCBSOtherDHS-245D