Healthcare Provider Details

I. General information

NPI: 1417954678
Provider Name (Legal Business Name): MARY ERIN KOPREVICH CRC, LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2005
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 GRAND ISLAND BLVD
GRAND ISLAND NY
14072-1693
US

IV. Provider business mailing address

1961 HARVEY RD
GRAND ISLAND NY
14072-2108
US

V. Phone/Fax

Practice location:
  • Phone: 716-573-7026
  • Fax: 716-773-5642
Mailing address:
  • Phone: 716-573-7026
  • Fax: 716-773-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number058006
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: