Basic Information
| Provider Information | |||||||||
| NPI: | 1417340928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACAITIS | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | MAY | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | QMHA, B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1118 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854949 | ||||||||
| FaxNumber: | 5035854965 | ||||||||
| Practice Location | |||||||||
| Address1: | 1118 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854949 | ||||||||
| FaxNumber: | 5035854965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2015 | ||||||||
| LastUpdateDate: | 03/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6472420 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041S0200X | 6472420 | OR | N | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.