Provider Demographics
NPI:1740325323
Name:MITYAGIN, SOPHIA A (PHD)
Entity type:Individual
Prefix:MS
First Name:SOPHIA
Middle Name:A
Last Name:MITYAGIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3538 LA ROCHELLE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221
Mailing Address - Country:US
Mailing Address - Phone:614-470-3095
Mailing Address - Fax:614-451-4117
Practice Address - Street 1:1570 FISHINGER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221
Practice Address - Country:US
Practice Address - Phone:614-470-3095
Practice Address - Fax:614-451-4117
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist