Provider Demographics
NPI:1588483077
Name:CERAVALO, SOPHIA DAE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:DAE
Last Name:CERAVALO
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 1:8512 CASTLEBAY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1877
Mailing Address - Country:US
Mailing Address - Phone:704-993-7155
Mailing Address - Fax:
Practice Address - Street 1:120 UNIONVILLE INDIAN TRAIL RD W STE 100
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5665
Practice Address - Country:US
Practice Address - Phone:704-438-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9053101Y00000X
NCA20522101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor