Healthcare Provider Details

I. General information

NPI: 1942729074
Provider Name (Legal Business Name): SOPHIA EVELYN MIMI GOLDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2017
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 NE GILMAN BLVD STE 100
ISSAQUAH WA
98027-2940
US

IV. Provider business mailing address

195 NE GILMAN BLVD STE 100
ISSAQUAH WA
98027-2940
US

V. Phone/Fax

Practice location:
  • Phone: 425-295-7697
  • Fax:
Mailing address:
  • Phone: 425-295-7697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: