Provider Demographics
NPI:1780016303
Name:DE SOUZA, TAILA DANE (DPT)
Entity Type:Individual
Prefix:MISS
First Name:TAILA
Middle Name:DANE
Last Name:DE SOUZA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4062 RUSTICO RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2342
Mailing Address - Country:US
Mailing Address - Phone:410-335-7898
Mailing Address - Fax:
Practice Address - Street 1:4062 RUSTICO RD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-2342
Practice Address - Country:US
Practice Address - Phone:410-335-7898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist