Healthcare Provider Details

I. General information

NPI: 1013342930
Provider Name (Legal Business Name): SOPHIA JUSTINE HENDERSON LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SOPHIA JUSTINE WILLIAMS

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MALONE RD
FORESTVILLE CA
95436-9597
US

IV. Provider business mailing address

7400 MALONE ROAD
FORESTVILLE CA
95436-1066
US

V. Phone/Fax

Practice location:
  • Phone: 707-529-8102
  • Fax:
Mailing address:
  • Phone: 707-529-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: