Provider Demographics
NPI:1043854193
Name:MCINTYRE, PAGE SOPHIA
Entity Type:Individual
Prefix:
First Name:PAGE
Middle Name:SOPHIA
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 POWERS STREET, APT 3RR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-0051
Mailing Address - Country:US
Mailing Address - Phone:845-519-0997
Mailing Address - Fax:
Practice Address - Street 1:935 S LAKE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-3222
Practice Address - Country:US
Practice Address - Phone:845-628-9284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP103310101YM0800X
NY103310-01101YM0800X
101YM0800X
NY104760-01225A00000X
NY011775101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist