Healthcare Provider Details

I. General information

NPI: 1518532878
Provider Name (Legal Business Name): SOPHIE SERCOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 BLUEBONNET BLVD
BATON ROUGE LA
70809-9633
US

IV. Provider business mailing address

4603 BLUEBONNET BLVD
BATON ROUGE LA
70809-9633
US

V. Phone/Fax

Practice location:
  • Phone: 225-802-2640
  • Fax:
Mailing address:
  • Phone: 225-802-2640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9486
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number011438283
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: