Healthcare Provider Details

I. General information

NPI: 1558416222
Provider Name (Legal Business Name): SOPHIA SONEN LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CENTER 4 CLEAN START 1001 LAKE STREET
SALISBURY MD
21801
US

IV. Provider business mailing address

512 M. GEORGIA AVENUE
SALISBURY MD
21801-5792
US

V. Phone/Fax

Practice location:
  • Phone: 410-742-3460
  • Fax: 410-742-5810
Mailing address:
  • Phone: 410-548-3716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA295
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: