Provider Demographics
NPI:1295581320
Name:IZYDOR, SOPHIA GABRIELLE
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:GABRIELLE
Last Name:IZYDOR
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WHALEN RD STE A
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1766
Mailing Address - Country:US
Mailing Address - Phone:855-444-5664
Mailing Address - Fax:
Practice Address - Street 1:901 WHALEN RD STE A
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1766
Practice Address - Country:US
Practice Address - Phone:855-444-5664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician