Provider Demographics
NPI:1366677494
Name:SOSA, INGRID C
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:C
Last Name:SOSA
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 1:9260 HAMMOCKS BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1584
Mailing Address - Country:US
Mailing Address - Phone:786-353-2900
Mailing Address - Fax:786-364-1676
Practice Address - Street 1:12700 SW 122ND AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5271
Practice Address - Country:US
Practice Address - Phone:786-353-2900
Practice Address - Fax:786-364-1676
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000879900Medicaid