Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 5306 | NC |
Y | 103T00000X | Psychologist | 5306 | NC |
N | 103TH0100X | Health Service | 5306 | NC |
NPI | 1003324336 |
---|---|
Provider Name | Dr. Thea Oculato Silva De Souza |
First Address | Charlotte, NC 28269-8923 |
Second Address | Cornelius, NC 28031-5641 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2018 |
Last Update Date | 10/01/2019 |