Healthcare Provider Details

I. General information

NPI: 1164671103
Provider Name (Legal Business Name): LAUREN EDNA KOPKA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 WAKELEE AVENUE
ANSONIA CT
06401-6079
US

IV. Provider business mailing address

121 WAKELEE AVE
ANSONIA CT
06401-1198
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3652
  • Fax: 203-503-3659
Mailing address:
  • Phone: 203-503-3652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8009
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: