Healthcare Provider Details

I. General information

NPI: 1619595238
Provider Name (Legal Business Name): SOFIA COLEEN NODALO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SOFIA COLEEN PABLEO

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 06/02/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 PICCARD DR STE 100
ROCKVILLE MD
20850-4368
US

IV. Provider business mailing address

1390 PICCARD DR STE 100
ROCKVILLE MD
20850-4368
US

V. Phone/Fax

Practice location:
  • Phone: 301-327-5199
  • Fax:
Mailing address:
  • Phone: 301-327-5199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-65996
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: