Provider Demographics
NPI:1093525743
Name:KISH, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:KISH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26513 GLENCOVE TRL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028-9835
Mailing Address - Country:US
Mailing Address - Phone:440-725-7434
Mailing Address - Fax:
Practice Address - Street 1:3929 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4153
Practice Address - Country:US
Practice Address - Phone:440-725-7434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2305400101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional