Healthcare Provider Details

I. General information

NPI: 1689329534
Provider Name (Legal Business Name): BETH COPPOLECCHIA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CHURCH HILL RD
NEWTOWN CT
06470-1637
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 475-828-0932
  • Fax: 475-209-8054
Mailing address:
  • Phone: 914-265-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6851
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: