Healthcare Provider Details

I. General information

NPI: 1457075210
Provider Name (Legal Business Name): SONA DILL PPS AND LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 E SAN FERNANDO ST UNIT 1102
SAN JOSE CA
95113-2542
US

IV. Provider business mailing address

88 E SAN FERNANDO ST UNIT 1102
SAN JOSE CA
95113-2542
US

V. Phone/Fax

Practice location:
  • Phone: 650-576-3791
  • Fax:
Mailing address:
  • Phone: 650-576-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP-4118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: