Healthcare Provider Details

I. General information

NPI: 1649003369
Provider Name (Legal Business Name): SOPHIA ELLA MARGARET MCCONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 PHOENIX DR STE 115
VIRGINIA BEACH VA
23452-7392
US

IV. Provider business mailing address

629 PHOENIX DR STE 115
VIRGINIA BEACH VA
23452-7392
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-4475
  • Fax: 757-222-3156
Mailing address:
  • Phone: 757-261-4475
  • Fax: 757-222-3156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204001473
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: