Provider Demographics
NPI:1235909862
Name:SOOGOFF, HENRIETTA ANNE (MS)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:ANNE
Last Name:SOOGOFF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:RETTA
Other - Middle Name:ANNE
Other - Last Name:SOOGOFF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:
Practice Address - Street 1:1063 MOSSER RD APT D104
Practice Address - Street 2:
Practice Address - City:BREINIGSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18031-1361
Practice Address - Country:US
Practice Address - Phone:949-282-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional