Basic Information
Provider Information
NPI: 1003011099
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FRY
FirstName: SONJA
MiddleName: ANNE
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 211 E 7TH AVE
Address2:  
City: EUGENE
State: OR
PostalCode: 974012773
CountryCode: US
TelephoneNumber: 5412420467
FaxNumber:  
Practice Location
Address1: 211 E 7TH AVE
Address2:  
City: EUGENE
State: OR
PostalCode: 974012773
CountryCode: US
TelephoneNumber: 5412420467
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/19/2007
LastUpdateDate: 12/13/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X  N Behavioral Health & Social Service ProvidersSocial Worker 
1041C0700XL4131ORY Behavioral Health & Social Service ProvidersSocial WorkerClinical

ID Information
IDTypeStateIssuerDescription
L413101ORVA EMPLOYEEOTHER


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