Healthcare Provider Details

I. General information

NPI: 1366352361
Provider Name (Legal Business Name): SOPHIA BLAYLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W. HAPPY VALLEY RD SUITE 4
PHOENIX AZ
85085
US

IV. Provider business mailing address

2501 W. HAPPY VALLEY RD SUITE 4 1002
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 602-501-8464
  • Fax:
Mailing address:
  • Phone: 602-501-8464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17604
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: