Provider Demographics
NPI:1255835468
Name:DESOUSA, COURTNEY L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:DESOUSA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5017
Mailing Address - Country:US
Mailing Address - Phone:774-644-1823
Mailing Address - Fax:
Practice Address - Street 1:863 HATHAWAY RD
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-1916
Practice Address - Country:US
Practice Address - Phone:508-996-6763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76804235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist