MEDICARE: LAURA SOFEN

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	235Z00000X	Speech-Language Pathologist	242004232	IL
2	235Z00000X	Speech-Language Pathologist	5399	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	242004232	OTHER	IL	SPEECH-LANGUAGE PATHOLOGY TEMPORARY LICENSE

General Provider Information

NPI Number	:	1700335320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA SOFEN

Provider Business Mailing Address
First Line	:	5026 N IDLEWILD AVE
Second Line	:
City	:	WHITEFISH BAY
State	:	WI
Zip	:	53217-5631
Country	:	US
Telephone Number	:	517-256-2638
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 N RACINE AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1532
Country	:	US
Telephone Number	:	517-256-2638
Fax Number	:

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

Provider Enumeration Date	:	09/23/2016
Last Update Date	:	12/21/2021

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Directions to “ LAURA SOFEN ” Practice Location

Language	Start Address	Practice Location

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