Healthcare Provider Details

I. General information

NPI: 1659994168
Provider Name (Legal Business Name): ANGELICA NOEL COPPOLA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3424 MOTOR AVE
LOS ANGELES CA
90034-4710
US

IV. Provider business mailing address

10720 LAKEWOOD BLVD APT 339
DOWNEY CA
90241-3598
US

V. Phone/Fax

Practice location:
  • Phone: 424-672-6700
  • Fax:
Mailing address:
  • Phone: 203-444-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-54237
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-69156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: