Provider Demographics
NPI:1336267996
Name:SOUZA, TAMMY ANDRA (MFT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:ANDRA
Last Name:SOUZA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W. PINE STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-712-9077
Mailing Address - Fax:209-468-8657
Practice Address - Street 1:404 W. PINE STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-712-9077
Practice Address - Fax:209-468-8657
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40641106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist