Healthcare Provider Details

I. General information

NPI: 1508970302
Provider Name (Legal Business Name): KATHI L KOPACZ LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W MAIN ST SUITE A
NEW MARKET MD
21774-6204
US

IV. Provider business mailing address

6135 BALDRIDGE TER
FREDERICK MD
21701-5858
US

V. Phone/Fax

Practice location:
  • Phone: 301-704-3546
  • Fax: 301-668-3076
Mailing address:
  • Phone: 301-704-3546
  • Fax: 301-668-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number04259
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: