Provider Demographics
NPI:1275155889
Name:ANTHONY, SOPHIA KATE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:KATE
Last Name:ANTHONY
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 1:2923 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1760
Mailing Address - Country:US
Mailing Address - Phone:503-941-0856
Mailing Address - Fax:
Practice Address - Street 1:2923 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1760
Practice Address - Country:US
Practice Address - Phone:503-941-0856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT2733106H00000X
WAMG61219076106H00000X
ORR7046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist