Basic Information
| Provider Information | |||||||||
| NPI: | 1861040040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUSA | ||||||||
| FirstName: | STACEY | ||||||||
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| Credential: | DPT, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 MAIN ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | TEWKSBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018764712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787106254 | ||||||||
| FaxNumber: | 9787106879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2019 | ||||||||
| LastUpdateDate: | 08/30/2019 | ||||||||
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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 | 24405 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.