Healthcare Provider Details

I. General information

NPI: 1396406294
Provider Name (Legal Business Name): SOPHIA PARISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 NESCONSET HWY
PORT JEFFERSON STATION NY
11776-2628
US

IV. Provider business mailing address

35 ONTARIO ST
PORT JEFFERSON STATION NY
11776-4345
US

V. Phone/Fax

Practice location:
  • Phone: 631-740-4306
  • Fax:
Mailing address:
  • Phone: 631-740-4306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number032054
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: