Provider Demographics
NPI:1497290647
Name:DESJARDINS, SOPHIA
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:DESJARDINS
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 1:603 PREBLE ST
Mailing Address - Street 2:APT. 1S
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-1032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 NORTHEAST RD
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:ME
Practice Address - Zip Code:04084-6495
Practice Address - Country:US
Practice Address - Phone:800-743-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOA3187224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1Medicaid