Provider Demographics
NPI:1194854596
Name:SONG, SOPHIA SUHYUN (LAC)
Entity Type:Individual
Prefix:MISS
First Name:SOPHIA
Middle Name:SUHYUN
Last Name:SONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MISS
Other - First Name:EUNJIN
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:2575 PALISADE AVE APT 4D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-6126
Mailing Address - Country:US
Mailing Address - Phone:347-202-8985
Mailing Address - Fax:347-202-8985
Practice Address - Street 1:984 N BROADWAY STE 400A
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1320
Practice Address - Country:US
Practice Address - Phone:914-329-6657
Practice Address - Fax:914-423-2378
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1407171100000X
NJ25MZ00023800171100000X
VA0121000158171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist