Provider Demographics
NPI:1073387429
Name:LAVERGNE, SOPHIE IRENE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:IRENE
Last Name:LAVERGNE
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 1:14411 BECKETT GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2138
Mailing Address - Country:US
Mailing Address - Phone:703-314-5734
Mailing Address - Fax:
Practice Address - Street 1:8700 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8430
Practice Address - Country:US
Practice Address - Phone:571-377-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204001127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist