Provider Demographics
NPI:1871318980
Name:SOBCZYK, MICAH (EDS)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:SOBCZYK
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 CONDUIT RD
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2625
Mailing Address - Country:US
Mailing Address - Phone:804-524-3445
Mailing Address - Fax:804-520-4342
Practice Address - Street 1:3451 CONDUIT RD
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2625
Practice Address - Country:US
Practice Address - Phone:804-524-3445
Practice Address - Fax:804-520-4342
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-534594103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool