Provider Demographics
NPI:1285174417
Name:BUBRICK, SOPHIA (OTR/L)
Entity type:Individual
Prefix:MS
First Name:SOPHIA
Middle Name:
Last Name:BUBRICK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MRS
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:SOPHIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:17330 HAMLIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5418
Mailing Address - Country:US
Mailing Address - Phone:310-975-9130
Mailing Address - Fax:
Practice Address - Street 1:415 N CRESCENT DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4860
Practice Address - Country:US
Practice Address - Phone:310-273-0877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15959225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty