Provider Demographics
NPI:1659036515
Name:DESOUSA, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DESOUSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 DEERHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-1123
Mailing Address - Country:US
Mailing Address - Phone:978-204-1288
Mailing Address - Fax:
Practice Address - Street 1:42 DEERHAVEN DR
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03064-1123
Practice Address - Country:US
Practice Address - Phone:978-204-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool