MEDICARE: SOPHIA WAGSTAFF RBT

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	106S00000X	Behavior Technician	RBT-25-430240	NV

General Provider Information

NPI Number	:	1548058118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA WAGSTAFF RBT

Provider Business Mailing Address
First Line	:	1060 WIGWAM PKWY
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-8162
Country	:	US
Telephone Number	:	702-547-6971
Fax Number	:

Provider Business Practice Location Address
First Line	:	3057 E WARM SPRINGS RD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3763
Country	:	US
Telephone Number	:	702-547-6971
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2025
Last Update Date	:	04/25/2025

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