Provider Demographics
NPI:1235206947
Name:D'SOUZA, CONNOLLY GLEESON (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNOLLY
Middle Name:GLEESON
Last Name:D'SOUZA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7182
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:3830 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1604
Practice Address - Country:US
Practice Address - Phone:305-442-1453
Practice Address - Fax:305-442-1466
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW83661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768008200Medicaid
FLBD968ZMedicare PIN
FLBD968YMedicare PIN