Healthcare Provider Details

I. General information

NPI: 1902046220
Provider Name (Legal Business Name): THERESA M DESOUZA CADCII, QHMA-I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 SW SCALEHOUSE CT
BEND OR
97702-3241
US

IV. Provider business mailing address

389 SW SCALEHOUSE CT
BEND OR
97702-3241
US

V. Phone/Fax

Practice location:
  • Phone: 541-306-4466
  • Fax:
Mailing address:
  • Phone: 541-306-4446
  • Fax: 541-550-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16-R-26
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25-QHMA-I005194
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: