Healthcare Provider Details

I. General information

NPI: 1033133798
Provider Name (Legal Business Name): ELISSA KAY KOPLIK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 S MAIN ST
MILLTOWN NJ
08850-1800
US

IV. Provider business mailing address

13 WILLIAMSBURG CT
EAST BRUNSWICK NJ
08816-3250
US

V. Phone/Fax

Practice location:
  • Phone: 732-246-4446
  • Fax:
Mailing address:
  • Phone: 732-613-9719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberSI4016
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: