Provider Demographics
NPI:1518532878
Name:SERCOVICH, SOPHIE
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:SERCOVICH
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 1:4603 BLUEBONNET BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9633
Mailing Address - Country:US
Mailing Address - Phone:225-802-2640
Mailing Address - Fax:
Practice Address - Street 1:4603 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9633
Practice Address - Country:US
Practice Address - Phone:225-802-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011438283106S00000X
LA9486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician