Provider Demographics
NPI:1962078972
Name:DESOUZA, BRENA
Entity type:Individual
Prefix:
First Name:BRENA
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 1:115 112TH AVE NE APT 323
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3255
Mailing Address - Country:US
Mailing Address - Phone:312-933-6011
Mailing Address - Fax:
Practice Address - Street 1:3491 GANDY BLVD N STE 201
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2654
Practice Address - Country:US
Practice Address - Phone:727-547-0607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health