MEDICARE: DR. PRISCILLA DREW SOUZA PHD LIC PSYCHOLOGIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	9940	TX
2	103TC0700X	Clinical Psychologist	32008	TX
3	103TC0700X	Clinical Psychologist	0810002647	VA

General Provider Information

NPI Number	:	1134450208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRISCILLA DREW SOUZA PHD LIC PSYCHOLOGIST

Provider Business Mailing Address
First Line	:	2600 LONE STAR DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75212-6326
Country	:	US
Telephone Number	:	214-424-5764
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 LONE STAR DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75212-6326
Country	:	US
Telephone Number	:	214-424-5764
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2010
Last Update Date	:	05/01/2015

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