Healthcare Provider Details

I. General information

NPI: 1588483077
Provider Name (Legal Business Name): SOPHIA DAE CERAVALO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 UNIONVILLE INDIAN TRAIL RD W STE 100
INDIAN TRAIL NC
28079-5665
US

IV. Provider business mailing address

8512 CASTLEBAY DR
CHARLOTTE NC
28277-1877
US

V. Phone/Fax

Practice location:
  • Phone: 704-438-9901
  • Fax:
Mailing address:
  • Phone: 704-993-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number9053
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA20522
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: