Healthcare Provider Details

I. General information

NPI: 1114703147
Provider Name (Legal Business Name): SOPHIA FOUNTOUKIDIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 DEVONSHIRE DR
SOMERSET NJ
08873-4948
US

IV. Provider business mailing address

56 DEVONSHIRE DR
SOMERSET NJ
08873-4948
US

V. Phone/Fax

Practice location:
  • Phone: 732-844-0349
  • Fax:
Mailing address:
  • Phone: 973-506-9345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC06616600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: