Provider Demographics
NPI:1720702715
Name:DESOUSA, ELMA
Entity Type:Individual
Prefix:
First Name:ELMA
Middle Name:
Last Name:DESOUSA
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 1:539 WASHINGTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2939
Mailing Address - Country:US
Mailing Address - Phone:401-871-4640
Mailing Address - Fax:
Practice Address - Street 1:895 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2902
Practice Address - Country:US
Practice Address - Phone:617-506-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health