MEDICARE: SOFA TIME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC003554	GA

General Provider Information

NPI Number	:	1205169349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOFA TIME, LLC

Provider Business Mailing Address
First Line	:	PO BOX 42251
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-0251
Country	:	US
Telephone Number	:	404-401-7619
Fax Number	:	404-696-7205

Provider Business Practice Location Address
First Line	:	2282 BOULEVARD GRANADA SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-3345
Country	:	US
Telephone Number	:	404-401-7619
Fax Number	:	404-696-7205

Authorized Official
Title or Position	:	OWNER/LPC
Name	:	DR. SONYA MARNIQUE ANDERSON
Credential	:	PH.D., LPC, NCC
Telephone Number	:	404-401-7619

Provider Enumeration Date	:	09/08/2009
Last Update Date	:	09/08/2009

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