Provider Demographics
NPI:1750165361
Name:BOISSEVAIN, SOPHIA CAMILLE (LMFT)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:CAMILLE
Last Name:BOISSEVAIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 GENOA PL APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-3429
Mailing Address - Country:US
Mailing Address - Phone:650-906-8628
Mailing Address - Fax:
Practice Address - Street 1:4341 1/2 CLARISSA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2801
Practice Address - Country:US
Practice Address - Phone:650-906-8628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA149492106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist