Provider Demographics
NPI:1285191262
Name:DESOUZA, FLAVIA
Entity Type:Individual
Prefix:
First Name:FLAVIA
Middle Name:
Last Name:DESOUZA
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 1:143 WEST ST STE V
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-3525
Mailing Address - Country:US
Mailing Address - Phone:860-799-5750
Mailing Address - Fax:
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-2310
Practice Address - Country:US
Practice Address - Phone:203-574-9000
Practice Address - Fax:203-574-9006
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1285191262Medicaid