Provider Demographics
NPI:1427519610
Name:SOFKO, CHANNING ANNE (PHD)
Entity type:Individual
Prefix:
First Name:CHANNING
Middle Name:ANNE
Last Name:SOFKO
Suffix:
Gender:F
Credentials:PHD
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 5005
Mailing Address - Street 2:
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BAY PINES VAHCS
Practice Address - Street 2:10000 BAY PINES BLVD
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01739103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical