Provider Demographics
NPI:1396989901
Name:SOPHOS WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:SOPHOS WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEBEL-KOMALA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:419-423-3292
Mailing Address - Street 1:PO BOX 8440
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-0440
Mailing Address - Country:US
Mailing Address - Phone:419-885-0200
Mailing Address - Fax:419-885-0203
Practice Address - Street 1:500 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-3544
Practice Address - Country:US
Practice Address - Phone:419-423-3292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6028103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty