Provider Demographics
NPI: | 1740735521 |
---|---|
Name: | SOLIS, SOPHIA VANESSA |
Entity Type: | Individual |
Prefix: | |
First Name: | SOPHIA |
Middle Name: | VANESSA |
Last Name: | SOLIS |
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: | 4283 EL CAJON BLVD |
Mailing Address - Street 2: | STE115 |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92105-1289 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 619-521-1896 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4283 EL CAJON BLVD |
Practice Address - Street 2: | STE 115 |
Practice Address - City: | SAN DIEGO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92105-1289 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-521-1896 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2016-08-22 |
Last Update Date: | 2023-07-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101Y00000X, 172V00000X | ||
D1268386 | 103K00000X | |
CA | D1268386 | 104100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 172V00000X | Other Service Providers | Community Health Worker | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker |