Provider Demographics
NPI:1386854669
Name:DESOUZA, JOAN (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:DESOUZA
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4169 MARIO CT
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-5132
Mailing Address - Country:US
Mailing Address - Phone:734-455-7024
Mailing Address - Fax:
Practice Address - Street 1:4169 MARIO CT
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-5132
Practice Address - Country:US
Practice Address - Phone:734-455-7024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical