Provider Demographics
NPI:1902517303
Name:PHILLIPS, SOFIA P
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:P
Last Name:PHILLIPS
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 1:445 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:614-844-3800
Mailing Address - Fax:
Practice Address - Street 1:1960 E COUNTY LINE RD STE 12
Practice Address - Street 2:
Practice Address - City:MINERAL RIDGE
Practice Address - State:OH
Practice Address - Zip Code:44440-9454
Practice Address - Country:US
Practice Address - Phone:330-571-9458
Practice Address - Fax:330-870-0097
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615030Medicaid