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General NPI Number Information
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NPI Number | 1588483077
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Entity Type | Individual
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Provider Name | SOPHIA DAE CERAVALO
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Gender | Female
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Dates
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Enumeration Date | 10/10/2024
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Last Update Date | 10/10/2024
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Provider Practice Location Address
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Address Line | 120 UNIONVILLE INDIAN TRAIL RD W STE 100
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City | INDIAN TRAIL
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State | NC
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Zip | 28079-5665
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Country | US
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Telephone | 704-438-9901
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Fax |
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Provider Business Mailing Address
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Address Line | 8512 CASTLEBAY DR
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City | CHARLOTTE
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State | NC
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Zip | 28277-1877
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Country | US
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Telephone | 704-993-7155
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 9053
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | A20522
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License Number State | NC
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