Healthcare Provider Details

I. General information

NPI: 1780758565
Provider Name (Legal Business Name): BERNARD JOSEPH SOUSSE M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 NORTHAMPTON ST
HOLYOKE MA
01040-1919
US

IV. Provider business mailing address

4 TAYLOR ST
HOLYOKE MA
01040-3328
US

V. Phone/Fax

Practice location:
  • Phone: 413-532-0926
  • Fax: 413-532-0928
Mailing address:
  • Phone: 413-210-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5362
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: