Healthcare Provider Details

I. General information

NPI: 1932279700
Provider Name (Legal Business Name): DIANE LEE KOPREVICH LCSWR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 S BUFFALO ST
HAMBURG NY
14075-6212
US

IV. Provider business mailing address

5793 STILWELL RD
HAMBURG NY
14075-5820
US

V. Phone/Fax

Practice location:
  • Phone: 716-648-0650
  • Fax: 716-648-0666
Mailing address:
  • Phone: 716-648-0650
  • Fax: 716-648-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number047102
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: