Provider Demographics
NPI:1073150710
Name:GOURLIDES, SOFIA (RDN, CDN, CLC)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:GOURLIDES
Suffix:
Gender:F
Credentials:RDN, CDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ELDERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-1549
Mailing Address - Country:US
Mailing Address - Phone:631-484-2366
Mailing Address - Fax:
Practice Address - Street 1:5 ELDERWOOD LN
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-1549
Practice Address - Country:US
Practice Address - Phone:631-484-2366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008813-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered