Healthcare Provider Details

I. General information

NPI: 1861014896
Provider Name (Legal Business Name): SOPHIA SAMADIAN M. ED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 GENERAL PERSHING BLVD
OKLAHOMA CITY OK
73107-6437
US

IV. Provider business mailing address

2501 PENDLETON DR APT 1608
NORMAN OK
73072-3468
US

V. Phone/Fax

Practice location:
  • Phone: 405-858-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: