Provider Demographics
NPI:1568717452
Name:DESOUZA, LAURA (LICSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DESOUZA
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 1:5004 WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1348
Mailing Address - Country:US
Mailing Address - Phone:612-616-8194
Mailing Address - Fax:
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker