Provider Demographics
NPI:1811626633
Name:BEZERRA DE SOUZA, ISABELA FERNANDA
Entity Type:Individual
Prefix:MRS
First Name:ISABELA
Middle Name:FERNANDA
Last Name:BEZERRA DE SOUZA
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 1:2501 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2505
Mailing Address - Country:US
Mailing Address - Phone:410-205-9493
Mailing Address - Fax:
Practice Address - Street 1:2501 SMITH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2505
Practice Address - Country:US
Practice Address - Phone:410-205-9493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician