Basic Information
Provider Information | |||||||||
NPI: | 1356078711 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DORANTES | ||||||||
FirstName: | SOFIA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7216 SE 16TH AVE | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972025811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7735544202 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2900 NW VINE ST | ||||||||
Address2: | UNITS D,E,F | ||||||||
City: | GRANTS PASS | ||||||||
State: | OR | ||||||||
PostalCode: | 97526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418164747 | ||||||||
FaxNumber: | 5417874011 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2022 | ||||||||
LastUpdateDate: | 08/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 16800 | OR | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.