Provider Demographics
NPI:1417738030
Name:REVERENDO, SOFIA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:MARIE
Last Name:REVERENDO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E 25TH ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3119
Mailing Address - Country:US
Mailing Address - Phone:908-967-3477
Mailing Address - Fax:
Practice Address - Street 1:3340 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2802
Practice Address - Country:US
Practice Address - Phone:718-696-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120660104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker