Basic Information
| Provider Information | |||||||||
| NPI: | 1780976241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUZA | ||||||||
| FirstName: | TAMARA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023685261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7817677531 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819619200 | ||||||||
| FaxNumber: | 7819616599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19199 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 19199 | 01 | MA | PT LICENSE | OTHER |