Provider Demographics
NPI:1336791961
Name:BOETTCHER, SOPHIA (BSCS, NC, MT, DD)
Entity Type:Individual
Prefix:MS
First Name:SOPHIA
Middle Name:
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:BSCS, NC, MT, DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 SANTANA HTS UNIT 3081
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:367 SANTANA HTS UNIT 4014
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2078
Practice Address - Country:US
Practice Address - Phone:425-961-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-13
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 156F00000X
CA156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No156F00000XEye and Vision Services ProvidersTechnician/Technologist