Provider Demographics
NPI:1376941112
Name:SOUSA, CORBETT A (LMSW)
Entity Type:Individual
Prefix:MR
First Name:CORBETT
Middle Name:A
Last Name:SOUSA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W USTICK RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6279
Mailing Address - Country:US
Mailing Address - Phone:208-453-8915
Mailing Address - Fax:
Practice Address - Street 1:420 W USTICK RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6279
Practice Address - Country:US
Practice Address - Phone:208-649-6048
Practice Address - Fax:208-906-2343
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34322104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker