Healthcare Provider Details

I. General information

NPI: 1932897451
Provider Name (Legal Business Name): LAURA BEATRIZ DE LIMA SOUZA BONASERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1966 FAUNA DR
FREDERICK MD
21702-1252
US

IV. Provider business mailing address

1966 FAUNA DR
FREDERICK MD
21702-1252
US

V. Phone/Fax

Practice location:
  • Phone: 224-284-4628
  • Fax:
Mailing address:
  • Phone: 224-284-4628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80179
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: