Healthcare Provider Details

I. General information

NPI: 1730620535
Provider Name (Legal Business Name): SOPHIA BURTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 FAIRWAY DR
MILL VALLEY CA
94941-1309
US

IV. Provider business mailing address

PO BOX 2279
MILL VALLEY CA
94942-2279
US

V. Phone/Fax

Practice location:
  • Phone: 401-688-0777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW02698
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number93400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: