Provider Demographics
NPI:1982195327
Name:DE SOUSA, DAVID J (LMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:DE SOUSA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 POTTING BENCH RD
Mailing Address - Street 2:
Mailing Address - City:MEREDITH
Mailing Address - State:NH
Mailing Address - Zip Code:03253-4212
Mailing Address - Country:US
Mailing Address - Phone:603-387-0950
Mailing Address - Fax:
Practice Address - Street 1:22 UPPER MILE POINT RD
Practice Address - Street 2:WELLNESS CENTER
Practice Address - City:MEREDITH
Practice Address - State:NH
Practice Address - Zip Code:03253-5741
Practice Address - Country:US
Practice Address - Phone:603-387-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4052225700000X
LA8782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8782OtherLICENSED MASSAGE THERAPIST
NH4052OtherLICENSED MASSAGE THERAPIST