Provider Demographics
NPI:1619217619
Name:GEORGOULIAS, SOFIA (PSYD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:GEORGOULIAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16704 GOTHIC DR
Mailing Address - Street 2:JAMAICA
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1911
Mailing Address - Country:US
Mailing Address - Phone:508-513-5443
Mailing Address - Fax:
Practice Address - Street 1:160 W 86TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-4018
Practice Address - Country:US
Practice Address - Phone:212-534-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
NY021123103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)