Healthcare Provider Details

I. General information

NPI: 1700876828
Provider Name (Legal Business Name): EVELYN KOPPEL MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 BLACKWOOD CLEMENTON RD
BLACKWOOD NJ
08012-4626
US

IV. Provider business mailing address

110 PENCOYO AVE
BALA CYNWYD PA
19004
US

V. Phone/Fax

Practice location:
  • Phone: 856-401-0557
  • Fax: 610-664-1007
Mailing address:
  • Phone: 856-401-0557
  • Fax: 610-664-1007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC00378
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: