Provider Demographics
NPI:1780347393
Name:ABDOU, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:ABDOU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 DATA DR APT 2313
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6451
Mailing Address - Country:US
Mailing Address - Phone:702-496-2382
Mailing Address - Fax:
Practice Address - Street 1:1620 SANTA CLARA DR STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3559
Practice Address - Country:US
Practice Address - Phone:916-786-3750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2025-04-23
Deactivation Date:2023-04-05
Deactivation Code:
Reactivation Date:2023-07-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker