Provider Demographics
NPI:1962140194
Name:COLON-REQUEJO, SOFIANYELI (PSYD, LP)
Entity type:Individual
Prefix:DR
First Name:SOFIANYELI
Middle Name:
Last Name:COLON-REQUEJO
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15578 EMPRESS AVE N UNIT 5
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4620
Mailing Address - Country:US
Mailing Address - Phone:787-988-9790
Mailing Address - Fax:
Practice Address - Street 1:680 STEWART AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-4117
Practice Address - Country:US
Practice Address - Phone:651-312-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6831103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program