Provider Demographics
NPI:1104120922
Name:TASOULIS, SOPHIA ANNEZA (OTR/L)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:ANNEZA
Last Name:TASOULIS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1709
Mailing Address - Country:US
Mailing Address - Phone:410-923-0187
Mailing Address - Fax:
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3109
Practice Address - Country:US
Practice Address - Phone:610-444-6350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-09
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02830225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation