Provider Demographics
NPI:1477903136
Name:GRIFFIN, SOTDERIA
Entity Type:Individual
Prefix:
First Name:SOTDERIA
Middle Name:
Last Name:GRIFFIN
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 1:879 WILLIAM BLVD APT 21C
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1571
Mailing Address - Country:US
Mailing Address - Phone:601-310-6900
Mailing Address - Fax:318-574-4407
Practice Address - Street 1:124 KIMBROUGH BLVD BLDG Q
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-4307
Practice Address - Country:US
Practice Address - Phone:318-574-4400
Practice Address - Fax:318-574-4407
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional