Provider Demographics
NPI:1992183388
Name:ANDERSON, SOPHIA LORRAINE
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:LORRAINE
Last Name:ANDERSON
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 1:22828 GAUKLER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2543
Mailing Address - Country:US
Mailing Address - Phone:586-944-0020
Mailing Address - Fax:
Practice Address - Street 1:22828 GAUKLER ST
Practice Address - Street 2:22828 GAUKLER STREET
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2543
Practice Address - Country:US
Practice Address - Phone:586-944-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIA536772546878261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care