Provider Demographics
NPI:1942246426
Name:TEDESCO SOUZA, MIRTA LILIANA (MS)
Entity Type:Individual
Prefix:MRS
First Name:MIRTA
Middle Name:LILIANA
Last Name:TEDESCO SOUZA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 EDWARDS AVE
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-2106
Mailing Address - Country:US
Mailing Address - Phone:508-675-1806
Mailing Address - Fax:
Practice Address - Street 1:151 ROCK ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3201
Practice Address - Country:US
Practice Address - Phone:508-678-7542
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health