Provider Demographics
NPI:1750054821
Name:KOUKOULIS, SOPHIA E
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:E
Last Name:KOUKOULIS
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 1:2394 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2524
Mailing Address - Country:US
Mailing Address - Phone:516-286-3335
Mailing Address - Fax:
Practice Address - Street 1:64 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-2999
Practice Address - Country:US
Practice Address - Phone:631-758-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health