Healthcare Provider Details

I. General information

NPI: 1346042918
Provider Name (Legal Business Name): SOPHIA MARIE YORK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 AMITY DR APT 304
FORT WAYNE IN
46845-9816
US

IV. Provider business mailing address

4625 AMITY DR APT 304
FORT WAYNE IN
46845-9816
US

V. Phone/Fax

Practice location:
  • Phone: 260-431-7625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22009031A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number39391
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: