Provider Demographics
NPI:1619780889
Name:FANARA, SOPHIA KIMBERLY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:KIMBERLY
Last Name:FANARA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 TITLEIST TRL
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-7808
Mailing Address - Country:US
Mailing Address - Phone:815-980-6216
Mailing Address - Fax:
Practice Address - Street 1:8201 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146018176235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist