Healthcare Provider Details

I. General information

NPI: 1265079453
Provider Name (Legal Business Name): SOPHIA ELIZABETH MARINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FCC PLAZA
KENNETT MO
63857
US

IV. Provider business mailing address

900 FCC PLAZA
KENNETT MO
63857
US

V. Phone/Fax

Practice location:
  • Phone: 573-772-2413
  • Fax:
Mailing address:
  • Phone: 573-772-2413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2025051812
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: