MEDICARE: SOPHIA KIANA CARTER PHD, LPC

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	101YM0800X	Mental Health Counselor	178018145	IL

General Provider Information

NPI Number	:	1942931233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA KIANA CARTER PHD, LPC

Provider Business Mailing Address
First Line	:	4012 S INDIANA AVE UNIT 4N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4778
Country	:	US
Telephone Number	:	773-610-5190
Fax Number	:

Provider Business Practice Location Address
First Line	:	4012 S INDIANA AVE UNIT 4N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4778
Country	:	US
Telephone Number	:	773-610-5190
Fax Number	:

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

Provider Enumeration Date	:	06/18/2022
Last Update Date	:	06/18/2022

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