Healthcare Provider Details

I. General information

NPI: 1972466365
Provider Name (Legal Business Name): MICHELLE KOPCHINSKY SIEGAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 NW 107TH AVE STE 109
SWEETWATER FL
33172-2739
US

IV. Provider business mailing address

20191 E COUNTRY CLUB DR APT 2707
AVENTURA FL
33180-3023
US

V. Phone/Fax

Practice location:
  • Phone: 786-762-2952
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28111
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: