Provider Demographics
NPI:1386463479
Name:SOUSA, MICHAEL J (MED, LADC 1)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SOUSA
Suffix:
Gender:M
Credentials:MED, LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 FARNHAM ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2962
Mailing Address - Country:US
Mailing Address - Phone:617-971-9360
Mailing Address - Fax:
Practice Address - Street 1:8 FARNHAM ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-2962
Practice Address - Country:US
Practice Address - Phone:508-241-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13160101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)