Healthcare Provider Details

I. General information

NPI: 1245726090
Provider Name (Legal Business Name): GEORGE MATTHEW SOUSA EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 BOUNDARY BLVD
ROTONDA WEST FL
33947-2033
US

IV. Provider business mailing address

575 BOUNDARY BLVD
ROTONDA WEST FL
33947-2033
US

V. Phone/Fax

Practice location:
  • Phone: 941-697-6907
  • Fax: 941-697-6907
Mailing address:
  • Phone: 941-697-6907
  • Fax: 941-697-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2150
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: