Provider Demographics
NPI:1417442484
Name:CORBETT SOUSA
Entity Type:Organization
Organization Name:CORBETT SOUSA
Other - Org Name:ACHIEVING FAMILY WELLNESS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING/BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-452-6580
Mailing Address - Street 1:16 12TH AVE S STE 208
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3937
Mailing Address - Country:US
Mailing Address - Phone:208-649-6048
Mailing Address - Fax:208-906-2343
Practice Address - Street 1:16 12TH AVE S STE 208
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3937
Practice Address - Country:US
Practice Address - Phone:208-649-6048
Practice Address - Fax:208-906-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID37239305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service