Provider Demographics
NPI:1124639653
Name:GARRETT, SOPHIA M (DPT)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:M
Last Name:GARRETT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E CHUBBUCK RD STE A
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5055
Mailing Address - Country:US
Mailing Address - Phone:208-417-0011
Mailing Address - Fax:888-437-2431
Practice Address - Street 1:265 E CHUBBUCK RD STE A
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5055
Practice Address - Country:US
Practice Address - Phone:208-417-0011
Practice Address - Fax:888-437-2431
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist