Provider Demographics
NPI:1578828059
Name:SOPHA, JULIE CHRISTEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:CHRISTEN
Last Name:SOPHA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:CHRISTEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1810 4TH ST SW STE 103A
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-4389
Mailing Address - Country:US
Mailing Address - Phone:319-352-1234
Mailing Address - Fax:319-352-4655
Practice Address - Street 1:1810 4TH ST SW STE 103A
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-4389
Practice Address - Country:US
Practice Address - Phone:319-352-1234
Practice Address - Fax:319-352-4655
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002045225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665992Medicaid
IA0665992Medicaid