{
"Npi": {
"NPI": "1194150235",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "BOULOS-SOPHY",
"FirstName": "SALLIE",
"MiddleName": "ANN",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "PHD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "11604 SANTA ELENA LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "AUSTIN",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "78717-5077",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "512-757-2641",
"MailingAddressFaxNumber": "512-467-8658",
"FirstLinePracticeLocationAddress": "4601 SPICEWOOD SPRINGS RD",
"SecondLinePracticeLocationAddress": "BLDG 4, SUITE 200",
"PracticeLocationAddressCityName": "AUSTIN",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "78759",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "512-467-1376",
"PracticeLocationAddressFaxNumber": "512-467-8658",
"EnumerationDate": "09/09/2013",
"LastUpdateDate": "12/31/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "103T00000X",
"TaxonomyName": "Psychologist",
"LicenseNumber": "36441",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}