Provider Demographics
NPI:1154873388
Name:SOUZA, ALICIAH KAE (BS)
Entity type:Individual
Prefix:
First Name:ALICIAH
Middle Name:KAE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E PECAN AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5124
Mailing Address - Country:US
Mailing Address - Phone:310-974-3055
Mailing Address - Fax:318-239-3867
Practice Address - Street 1:644 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4619
Practice Address - Country:US
Practice Address - Phone:318-239-3862
Practice Address - Fax:318-239-3867
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA471411453101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health