1225651938 NPI number — SADIE TEAGAN ANGELIQUE SOUZA LPC

Table of content: SADIE TEAGAN ANGELIQUE SOUZA LPC (NPI 1225651938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225651938 NPI number — SADIE TEAGAN ANGELIQUE SOUZA LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUZA
Provider First Name:
SADIE
Provider Middle Name:
TEAGAN ANGELIQUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOUZA
Provider Other First Name:
SADIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225651938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1787
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97501-0261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-500-8655
Provider Business Mailing Address Fax Number:
800-433-1396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 CRATER LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-7444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-227-6687
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  C9710 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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