Healthcare Provider Details

I. General information

NPI: 1154691384
Provider Name (Legal Business Name): SALINA MARIE KOPP PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N CHASE ST
JOHNSTOWN NY
12095-1810
US

IV. Provider business mailing address

207 N CHASE ST
JOHNSTOWN NY
12095-1810
US

V. Phone/Fax

Practice location:
  • Phone: 518-848-6583
  • Fax:
Mailing address:
  • Phone: 518-848-6583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number005889-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: