Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1023575156 |
---|---|
Provider Name | Sophia Gillen |
First Address | Huntington Park, CA 90255-3699 |
Second Address | Huntington Park, CA 90255-3699 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/02/2019 |
Last Update Date | 25/02/2019 |