Provider Demographics
NPI:1982364477
Name:SOUZA, GRACIELLE SOARES DE
Entity Type:Individual
Prefix:
First Name:GRACIELLE
Middle Name:SOARES DE
Last Name:SOUZA
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 1:14 CAPITAL PL
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3445
Mailing Address - Country:US
Mailing Address - Phone:516-988-3578
Mailing Address - Fax:
Practice Address - Street 1:14 CAPITAL PL
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3445
Practice Address - Country:US
Practice Address - Phone:516-988-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator