Healthcare Provider Details

I. General information

NPI: 1225548209
Provider Name (Legal Business Name): SOFIA EKATERINA PETTYGROVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 COFFEE RD STE A-5
MODESTO CA
95355-2427
US

IV. Provider business mailing address

PO BOX 581921
MODESTO CA
95358-0033
US

V. Phone/Fax

Practice location:
  • Phone: 209-338-7361
  • Fax: 209-232-7093
Mailing address:
  • Phone: 209-338-7361
  • Fax: 209-232-7093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number123864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: