Provider Demographics
NPI:1316309503
Name:DESOUZA, FLAVIA
Entity type:Individual
Prefix:
First Name:FLAVIA
Middle Name:
Last Name:DESOUZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15146 HASTINGS DR
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419-2904
Mailing Address - Country:US
Mailing Address - Phone:860-301-3140
Mailing Address - Fax:
Practice Address - Street 1:2041 GEORGIA AVE NW STE 6101
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20060-6624
Practice Address - Country:US
Practice Address - Phone:202-865-6679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0486112084P0800X
390200000X
CT615812084P0800X
IL0361531562084P0800X
CAA1695892084P0800X
MI43015128242084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program