Provider Demographics
NPI:1609517366
Name:GARCIA SOTO, ANDY JULISSA (LMT)
Entity type:Individual
Prefix:MISS
First Name:ANDY
Middle Name:JULISSA
Last Name:GARCIA SOTO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 N JONES RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-3508
Mailing Address - Country:US
Mailing Address - Phone:631-494-0466
Mailing Address - Fax:
Practice Address - Street 1:115 BROADHOLLOW RD STE 10
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4992
Practice Address - Country:US
Practice Address - Phone:631-990-4352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY114427-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
79507690000OtherOXFORD LIBERTY