Provider Demographics
NPI:1235350448
Name:PRUM, SOPHEA (MASTERS)
Entity Type:Individual
Prefix:MRS
First Name:SOPHEA
Middle Name:
Last Name:PRUM
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:SOPHEA
Other - Middle Name:
Other - Last Name:SOUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:99 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2621
Mailing Address - Country:US
Mailing Address - Phone:978-458-6282
Mailing Address - Fax:978-441-9826
Practice Address - Street 1:99 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-458-6282
Practice Address - Fax:978-441-9826
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1729106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist