Healthcare Provider Details

I. General information

NPI: 1770064842
Provider Name (Legal Business Name): DR. SILVA DE SOUZA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18151 W CATAWBA AVE
CORNELIUS NC
28031
US

IV. Provider business mailing address

18151 W CATAWBA AVE
CORNELIUS NC
28031-5641
US

V. Phone/Fax

Practice location:
  • Phone: 704-495-4435
  • Fax:
Mailing address:
  • Phone: 704-495-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number5306
License Number StateNC

VIII. Authorized Official

Name: DR. THEA OCULATO SILVA DE SOUZA
Title or Position: OWNER
Credential: PH.D.
Phone: 917-589-5372