Basic Information
| Provider Information | |||||||||
| NPI: | 1104399534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | SOPHIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 200 | ||||||||
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| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910302694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233415580 | ||||||||
| FaxNumber: | 3233408298 | ||||||||
| Practice Location | |||||||||
| Address1: | 1742 CROOKS RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480845501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485440360 | ||||||||
| FaxNumber: | 2485440388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2019 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N |
No ID Information.