Healthcare Provider Details

I. General information

NPI: 1427781384
Provider Name (Legal Business Name): SOPHIA M OU MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N MICHIGAN AVE STE 810
CHICAGO IL
60601-5902
US

IV. Provider business mailing address

205 N MICHIGAN AVE STE 810
CHICAGO IL
60601-5902
US

V. Phone/Fax

Practice location:
  • Phone: 773-358-6684
  • Fax: 872-264-4585
Mailing address:
  • Phone: 773-358-6684
  • Fax: 872-264-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.018767
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: