Provider Demographics
NPI:1518664408
Name:PETERSON, SOPHIE ROSE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:ROSE
Last Name:PETERSON
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 1:1325 W WILSON AVE UNIT 910
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6229
Mailing Address - Country:US
Mailing Address - Phone:312-623-1842
Mailing Address - Fax:
Practice Address - Street 1:1325 W WILSON AVE UNIT 910
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-6229
Practice Address - Country:US
Practice Address - Phone:312-623-1842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0251811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical