Healthcare Provider Details

I. General information

NPI: 1336976216
Provider Name (Legal Business Name): SOPHIA GOLDSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 DANBY RD
ITHACA NY
14850-7000
US

IV. Provider business mailing address

320 PLEASANT ST
ITHACA NY
14850-5710
US

V. Phone/Fax

Practice location:
  • Phone: 508-808-4554
  • Fax:
Mailing address:
  • Phone: 508-808-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: