Healthcare Provider Details

I. General information

NPI: 1780944975
Provider Name (Legal Business Name): MS. FLAVIA LOPES SOARES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W 71ST ST
NEW YORK NY
10023-3766
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5002
US

V. Phone/Fax

Practice location:
  • Phone: 212-799-0160
  • Fax: 212-799-0209
Mailing address:
  • Phone: 631-359-5859
  • Fax: 631-396-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number039419-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: