Provider Demographics
NPI:1578021127
Name:DESUZA, GWENETH LOURECIA (SOCIAL WORKER)
Entity Type:Individual
Prefix:
First Name:GWENETH
Middle Name:LOURECIA
Last Name:DESUZA
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W MOSHOLU PKWY S APT 35G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1146
Mailing Address - Country:US
Mailing Address - Phone:347-839-1224
Mailing Address - Fax:718-367-9582
Practice Address - Street 1:40 W MOSHOLU PKWY S APT 35G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1146
Practice Address - Country:US
Practice Address - Phone:347-839-1224
Practice Address - Fax:718-367-9582
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075254-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker