Healthcare Provider Details

I. General information

NPI: 1346573607
Provider Name (Legal Business Name): SOPHIA C LAURITSEN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-7225
  • Fax:
Mailing address:
  • Phone: 505-629-7225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0144901
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: