Healthcare Provider Details

I. General information

NPI: 1376142653
Provider Name (Legal Business Name): MARISA KOPA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 01/24/2022
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FORTUNE RD W
MIDDLETOWN NY
10941-1625
US

IV. Provider business mailing address

15 FORTUNE RD W
MIDDLETOWN NY
10941-1625
US

V. Phone/Fax

Practice location:
  • Phone: 845-343-5556
  • Fax: 845-343-3341
Mailing address:
  • Phone: 845-343-5556
  • Fax: 845-343-3341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number110334-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: