Provider Demographics
NPI:1487391777
Name:REDONDO, SOPHIA MARIE (CADC-II,ICADC)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:MARIE
Last Name:REDONDO
Suffix:
Gender:F
Credentials:CADC-II,ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 S STATE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4922
Mailing Address - Country:US
Mailing Address - Phone:951-791-3350
Mailing Address - Fax:
Practice Address - Street 1:1370 S STATE ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4922
Practice Address - Country:US
Practice Address - Phone:951-791-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CACI22441021101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator