Provider Demographics
NPI:1912475054
Name:ETIENNE, SOPHINA A
Entity Type:Individual
Prefix:
First Name:SOPHINA
Middle Name:A
Last Name:ETIENNE
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 1:440 ELM ST APT 8
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-2344
Mailing Address - Country:US
Mailing Address - Phone:978-962-8866
Mailing Address - Fax:
Practice Address - Street 1:440 ELM ST APT 8
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-2344
Practice Address - Country:US
Practice Address - Phone:978-962-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician