Provider Demographics
NPI:1770892200
Name:LOPEZ CRISOSTOMO, SOFIA MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:SOFIA
Middle Name:MARIE
Last Name:LOPEZ CRISOSTOMO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:SOFIA
Other - Middle Name:MARIE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4016 RAINTREE RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3700
Mailing Address - Country:US
Mailing Address - Phone:757-488-2864
Mailing Address - Fax:757-488-4735
Practice Address - Street 1:4016 RAINTREE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3700
Practice Address - Country:US
Practice Address - Phone:757-488-2864
Practice Address - Fax:757-488-4735
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052041682251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004979061Medicaid
VA496668Medicare PIN