Provider Demographics
NPI:1467059584
Name:O'LEARY, SOFIA ERIN
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:ERIN
Last Name:O'LEARY
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 1:11602 N 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2132
Mailing Address - Country:US
Mailing Address - Phone:863-619-2809
Mailing Address - Fax:
Practice Address - Street 1:7421 SW 174TH ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6306
Practice Address - Country:US
Practice Address - Phone:972-742-7784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136412106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician