Healthcare Provider Details

I. General information

NPI: 1386083012
Provider Name (Legal Business Name): MARIO ANTONIO SOUZA PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2013
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E HIGHLAND AVE
PATTON CA
92369-7813
US

IV. Provider business mailing address

3404 SANTA CARLOTTA ST
LA CRESCENTA CA
91214-1158
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7000
  • Fax:
Mailing address:
  • Phone: 818-395-0331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberD6738240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: