Provider Demographics
NPI:1548909302
Name:SOFYAN, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:SOFYAN
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 1:1408 S BEVERLY GLEN BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6127
Mailing Address - Country:US
Mailing Address - Phone:909-260-8192
Mailing Address - Fax:
Practice Address - Street 1:6041 CADILLAC AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1702
Practice Address - Country:US
Practice Address - Phone:909-260-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20174225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist