Provider Demographics
NPI:1134717663
Name:HANSEN, SOPHIA BRETT
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:BRETT
Last Name:HANSEN
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:PO BOX 290087
Mailing Address - Street 2:
Mailing Address - City:YIGO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-3031
Mailing Address - Country:US
Mailing Address - Phone:858-926-6193
Mailing Address - Fax:
Practice Address - Street 1:643 CHALAN SAN ANTONIO
Practice Address - Street 2:STE 108
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3644
Practice Address - Country:US
Practice Address - Phone:858-926-6193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299263225100000X
GUPT-164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist