Healthcare Provider Details

I. General information

NPI: 1962058180
Provider Name (Legal Business Name): SOFIA VAKSMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 E 18TH ST
BROOKLYN NY
11229-1249
US

IV. Provider business mailing address

180 STONEGATE DR
STATEN ISLAND NY
10304-4444
US

V. Phone/Fax

Practice location:
  • Phone: 917-669-2359
  • Fax:
Mailing address:
  • Phone: 917-669-2359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number081657
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: