Provider Demographics
NPI:1801788542
Name:FORMOSA, SOPHIA
Entity type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:
Last Name:FORMOSA
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:WHITETHORN
Mailing Address - State:CA
Mailing Address - Zip Code:95589-0092
Mailing Address - Country:US
Mailing Address - Phone:415-490-8308
Mailing Address - Fax:
Practice Address - Street 1:733 CEDAR ST
Practice Address - Street 2:
Practice Address - City:GARBERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95542-3201
Practice Address - Country:US
Practice Address - Phone:707-923-3921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53577225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant