Provider Demographics
NPI:1811045008
Name:SOPHIA, SUSAN (OT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:SOPHIA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MIKULKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2724 MORNINGSIDE DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2940
Mailing Address - Country:US
Mailing Address - Phone:505-883-3102
Mailing Address - Fax:505-872-9174
Practice Address - Street 1:2724 MORNINGSIDE DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2940
Practice Address - Country:US
Practice Address - Phone:505-883-3102
Practice Address - Fax:505-872-9174
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM329225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60080086Medicaid