Provider Demographics
NPI:1740604966
Name:SOUZA, KAREN
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:SOUZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 78000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:399 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5384
Practice Address - Country:US
Practice Address - Phone:614-355-8550
Practice Address - Fax:614-355-8593
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF1600011106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid