Healthcare Provider Details

I. General information

NPI: 1669979258
Provider Name (Legal Business Name): SOPHIA LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOPHIA CAMPBELL

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7389 AIRPORT VIEW DR SW
ROCHESTER MN
55902-1890
US

IV. Provider business mailing address

818 NORTH BLVD
OAK PARK IL
60301-1302
US

V. Phone/Fax

Practice location:
  • Phone: 507-292-1006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4679
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: