MEDICARE: MS. SOPHIE ELLA GREEN ATR-BC, LCAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	221700000X	Art Therapist	002005-01	NY

General Provider Information

NPI Number	:	1437824646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SOPHIE ELLA GREEN ATR-BC, LCAT

Provider Business Mailing Address
First Line	:	250 DEAN ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-2201
Country	:	US
Telephone Number	:	347-880-2329
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 DEAN ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-2201
Country	:	US
Telephone Number	:	347-880-2329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2021
Last Update Date	:	08/19/2021

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