Provider Demographics
NPI:1013430628
Name:DEHAVEN, SOPHIE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:DEHAVEN
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 1:1142 CORRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8415
Mailing Address - Country:US
Mailing Address - Phone:314-275-8283
Mailing Address - Fax:
Practice Address - Street 1:4700 BELLEVIEW AVE STE 415
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64112-1361
Practice Address - Country:US
Practice Address - Phone:816-569-2802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017026176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist