Provider Demographics
NPI:1558759365
Name:DE MOURA SOUZA, MIRIAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:MIRIAN
Middle Name:
Last Name:DE MOURA SOUZA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11371 RIVERPASS CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-5162
Mailing Address - Country:US
Mailing Address - Phone:949-302-3948
Mailing Address - Fax:
Practice Address - Street 1:11371 RIVERPASS CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5162
Practice Address - Country:US
Practice Address - Phone:949-302-3948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2865224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant