Provider Demographics
NPI:1700523073
Name:DESOUZA, SHAUNA TESONA
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:TESONA
Last Name:DESOUZA
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 1:19908 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3802
Mailing Address - Country:US
Mailing Address - Phone:191-750-0870
Mailing Address - Fax:
Practice Address - Street 1:19908 120TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3802
Practice Address - Country:US
Practice Address - Phone:917-500-8705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2694593103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst