Provider Demographics
NPI:1568755312
Name:CHAMBERLAIN, SOPHIA MARILYN
Entity Type:Individual
Prefix:MISS
First Name:SOPHIA
Middle Name:MARILYN
Last Name:CHAMBERLAIN
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:PO BOX 11971
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64138-0971
Mailing Address - Country:US
Mailing Address - Phone:816-337-2799
Mailing Address - Fax:
Practice Address - Street 1:10635 FLOYD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-2548
Practice Address - Country:US
Practice Address - Phone:816-337-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO856348404320900000X
MO856178603320900000X
MO856243308320900000X
MO856142906320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1609992635Medicaid
MO1164601563Medicaid
MO1043337942Medicaid
MO1396862298Medicaid