Provider Demographics
NPI:1376836635
Name:SOUZA, STEPHANIE ANN (LSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:SOUZA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-2084
Mailing Address - Country:US
Mailing Address - Phone:419-460-4318
Mailing Address - Fax:
Practice Address - Street 1:2600 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2084
Practice Address - Country:US
Practice Address - Phone:419-460-4318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1000765104100000X
OHS.10007651041C0700X
OHI.12015581041C0700X
OHI.1201558-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH161183Medicaid
OHS1000765OtherSTATE OF OHIO COUNSELOR, SOCIAL WORKER, MARRIAGE FAMILY THERAPIST BOARD