Provider Demographics
NPI:1518453133
Name:VASILYEVA, SOFYA OLEGOVNA
Entity Type:Individual
Prefix:
First Name:SOFYA
Middle Name:OLEGOVNA
Last Name:VASILYEVA
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 1:4892 SAN PABLO DAM RD
Mailing Address - Street 2:
Mailing Address - City:EL SOBRANTE
Mailing Address - State:CA
Mailing Address - Zip Code:94803-3222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:433 TURK ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-3329
Practice Address - Country:US
Practice Address - Phone:917-355-1448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAR1324361018101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program