Provider Demographics
NPI:1205514627
Name:ELLIOTT, SOPHIA MARIE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:MARIE
Last Name:ELLIOTT
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 1:17951 JEFFERSON PARK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-8439
Mailing Address - Country:US
Mailing Address - Phone:440-879-8517
Mailing Address - Fax:
Practice Address - Street 1:17951 JEFFERSON PARK RD STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-8439
Practice Address - Country:US
Practice Address - Phone:440-879-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional