1366000911 NPI number — MRS. SOPHIA CORRINE SOLEIL DAWSON LSW, LCSW

Table of content: MRS. SOPHIA CORRINE SOLEIL DAWSON LSW, LCSW (NPI 1366000911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366000911 NPI number — MRS. SOPHIA CORRINE SOLEIL DAWSON LSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAWSON
Provider First Name:
SOPHIA
Provider Middle Name:
CORRINE SOLEIL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
SOPHIA
Provider Other Middle Name:
CORRINE SOLEIL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LSW, LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366000911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3420 N ROCHELLE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61604-1035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-282-1087
Provider Business Mailing Address Fax Number:
309-282-1089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 W NEW LEAF LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61615-3311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-589-1011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149.020911 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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