Provider Demographics
NPI:1518944065
Name:SOUZA, SUZANNE MARY (DPT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARY
Last Name:SOUZA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3656
Mailing Address - Country:US
Mailing Address - Phone:510-524-2177
Mailing Address - Fax:
Practice Address - Street 1:425 KEARNEY ST
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3656
Practice Address - Country:US
Practice Address - Phone:510-524-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 28942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13096Medicare ID - Type UnspecifiedGROUP