Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 380932 | OR |
NPI | 1043747660 |
---|---|
Provider Name | Courtney Souza |
First Address | Portland, OR 97219-1943 |
Second Address | Forest Grove, OR 97116-2226 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2017 |
Last Update Date | 13/05/2017 |