Provider Demographics
NPI:1114540481
Name:SOUZA, COURTNEY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SOUZA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 FURNACE BROOK PKWY APT 4
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1654
Mailing Address - Country:US
Mailing Address - Phone:617-429-5453
Mailing Address - Fax:
Practice Address - Street 1:1266 FURNACE BROOK PKWY STE 100B
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4789
Practice Address - Country:US
Practice Address - Phone:617-433-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77528-SP-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist