Provider Demographics
NPI:1396033569
Name:MAINES, SOPHIA RUTH (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:RUTH
Last Name:MAINES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 KODIAK TRL
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4108
Mailing Address - Country:US
Mailing Address - Phone:512-429-2975
Mailing Address - Fax:
Practice Address - Street 1:2324 E CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4604
Practice Address - Country:US
Practice Address - Phone:512-522-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19622225100000X
TX1244873225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist