Provider Demographics
NPI:1639495401
Name:SOUZA, MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:SOUZA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3395
Mailing Address - Country:US
Mailing Address - Phone:508-941-7000
Mailing Address - Fax:
Practice Address - Street 1:31 ROCHE BROTHERS WAY
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1032
Practice Address - Country:US
Practice Address - Phone:508-894-8730
Practice Address - Fax:508-894-8732
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORM4970104100000X
ORA4970104100000X
MA217472104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500643886Medicaid