Provider Demographics
NPI:1265089197
Name:CHAN, SOPHIA (OT)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14414 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3721
Mailing Address - Country:US
Mailing Address - Phone:917-655-9972
Mailing Address - Fax:
Practice Address - Street 1:8170 MURRAY AVE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4605
Practice Address - Country:US
Practice Address - Phone:408-842-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2025-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023032225X00000X
CA23826225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist