Provider Demographics
NPI:1245515402
Name:AZEVEDO, SONIA P (PHD)
Entity type:Individual
Prefix:
First Name:SONIA
Middle Name:P
Last Name:AZEVEDO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EMORY ROAD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501
Mailing Address - Country:US
Mailing Address - Phone:516-237-2549
Mailing Address - Fax:516-237-2508
Practice Address - Street 1:200 EMORY RD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2363
Practice Address - Country:US
Practice Address - Phone:516-237-2549
Practice Address - Fax:516-237-2508
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014982-1251300000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist