Provider Demographics
NPI:1245726090
Name:SOUSA, GEORGE MATTHEW (EDD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:MATTHEW
Last Name:SOUSA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 BOUNDARY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROTONDA WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33947-2033
Mailing Address - Country:US
Mailing Address - Phone:941-697-6907
Mailing Address - Fax:941-697-6907
Practice Address - Street 1:575 BOUNDARY BLVD
Practice Address - Street 2:
Practice Address - City:ROTONDA WEST
Practice Address - State:FL
Practice Address - Zip Code:33947-2033
Practice Address - Country:US
Practice Address - Phone:941-697-6907
Practice Address - Fax:941-697-6907
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2150103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical