Healthcare Provider Details

I. General information

NPI: 1972232833
Provider Name (Legal Business Name): TANISHA A COPPIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 SOUTH LAKE AVE
ALBANY NY
12208
US

IV. Provider business mailing address

75 NEW SCOTLAND AVE
ALBANY NY
12208-3409
US

V. Phone/Fax

Practice location:
  • Phone: 518-549-6400
  • Fax:
Mailing address:
  • Phone: 518-549-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: