Healthcare Provider Details

I. General information

NPI: 1306082995
Provider Name (Legal Business Name): SOPHIA S NAKABAYASHI M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 GRAND VIEW BLVD
LOS ANGELES CA
90066-5214
US

IV. Provider business mailing address

4160 GRAND VIEW BLVD
LOS ANGELES CA
90066-5214
US

V. Phone/Fax

Practice location:
  • Phone: 310-751-1145
  • Fax:
Mailing address:
  • Phone: 310-751-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number55964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: