Healthcare Provider Details

I. General information

NPI: 1669395075
Provider Name (Legal Business Name): SOPHIA ANN THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14813 W 101ST AVE
DYER IN
46311-3027
US

IV. Provider business mailing address

10431 ADLER CV
SAINT JOHN IN
46373-8786
US

V. Phone/Fax

Practice location:
  • Phone: 219-245-7970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2832784
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: