Provider Demographics
NPI:1700335320
Name:SOFEN, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SOFEN
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 1:5026 N IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5631
Mailing Address - Country:US
Mailing Address - Phone:517-256-2638
Mailing Address - Fax:
Practice Address - Street 1:3535 N RACINE AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1532
Practice Address - Country:US
Practice Address - Phone:517-256-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242004232235Z00000X
WI5399235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL242004232OtherSPEECH-LANGUAGE PATHOLOGY TEMPORARY LICENSE