Provider Demographics
NPI:1356212716
Name:DESOUSA, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:DESOUSA
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 1:7 GROOM CT
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-7655
Mailing Address - Country:US
Mailing Address - Phone:732-547-4063
Mailing Address - Fax:
Practice Address - Street 1:615 HOPE RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1277
Practice Address - Country:US
Practice Address - Phone:732-858-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC065465001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty