Provider Demographics
NPI:1225548209
Name:PETTYGROVE, SOFIA EKATERINA
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:EKATERINA
Last Name:PETTYGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 581921
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-0033
Mailing Address - Country:US
Mailing Address - Phone:209-338-7361
Mailing Address - Fax:209-232-7093
Practice Address - Street 1:2020 COFFEE RD STE A-5
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2427
Practice Address - Country:US
Practice Address - Phone:209-338-7361
Practice Address - Fax:209-232-7093
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
CA123864101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional