Provider Demographics
NPI:1366685786
Name:SOUZA, JOHN ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name: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 1:5309 WOOD LAKE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-5747
Mailing Address - Country:US
Mailing Address - Phone:573-499-1873
Mailing Address - Fax:
Practice Address - Street 1:5309 WOOD LAKE CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-5747
Practice Address - Country:US
Practice Address - Phone:573-499-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0001171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical