Healthcare Provider Details

I. General information

NPI: 1114386927
Provider Name (Legal Business Name): SOFIA KHERAJ LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 N CAMPBELL AVE # 2C
CHICAGO IL
60622-5457
US

IV. Provider business mailing address

803 N CAMPBELL AVE # 2C
CHICAGO IL
60622-5457
US

V. Phone/Fax

Practice location:
  • Phone: 214-223-6142
  • Fax:
Mailing address:
  • Phone: 214-223-6142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180008962
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: