Provider Demographics
NPI:1386083012
Name:SOUZA, MARIO ANTONIO (PSYD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ANTONIO
Last Name:SOUZA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 SANTA CARLOTTA ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1158
Mailing Address - Country:US
Mailing Address - Phone:818-395-0331
Mailing Address - Fax:
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAD6738240103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)