Provider Demographics
NPI:1558878264
Name:SOUSA, TAVERLY JUDE (LICSW)
Entity Type:Individual
Prefix:
First Name:TAVERLY
Middle Name:JUDE
Last Name:SOUSA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 POND AVE # B207
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7163
Mailing Address - Country:US
Mailing Address - Phone:617-739-0075
Mailing Address - Fax:
Practice Address - Street 1:33 POND AVE # B207
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7163
Practice Address - Country:US
Practice Address - Phone:617-739-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA106122OtherLICENSED INDEPENDANT CLINICAL SOCIAL WORKER