Healthcare Provider Details

I. General information

NPI: 1588390389
Provider Name (Legal Business Name): SOPHIE GLOECKLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 MADISON AVE RM 1501
NEW YORK NY
10016-0701
US

IV. Provider business mailing address

36 SARITA RD
TAOS NM
87571-6833
US

V. Phone/Fax

Practice location:
  • Phone: 212-203-1773
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF404211-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: