Provider Demographics
NPI:1619180262
Name:SOUZA, SANDRA L (BC-HIS,ACA)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:L
Last Name:SOUZA
Suffix:
Gender:F
Credentials:BC-HIS,ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13759
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-3759
Mailing Address - Country:US
Mailing Address - Phone:805-547-9500
Mailing Address - Fax:805-547-9502
Practice Address - Street 1:3830 BROAD ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7187
Practice Address - Country:US
Practice Address - Phone:805-547-9500
Practice Address - Fax:805-547-9502
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3908237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist