Provider Demographics
NPI:1649655085
Name:TICAS, SOFIA
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:TICAS
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 1:6600 W CHARLESTON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1067
Mailing Address - Country:US
Mailing Address - Phone:702-690-1865
Mailing Address - Fax:
Practice Address - Street 1:6600 W CHARLESTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1067
Practice Address - Country:US
Practice Address - Phone:702-690-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT6406225700000X
NV680240156171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171W00000XOther Service ProvidersContractor