Provider Demographics
NPI:1649922907
Name:FATEHI, SOGOL
Entity type:Individual
Prefix:
First Name:SOGOL
Middle Name:
Last Name:FATEHI
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 1:35 HOYA ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92694-1283
Mailing Address - Country:US
Mailing Address - Phone:612-836-8118
Mailing Address - Fax:
Practice Address - Street 1:24002 VIA FABRICANTE STE 501
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3934
Practice Address - Country:US
Practice Address - Phone:949-454-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT301513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist