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General NPI Number Information
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NPI Number | 1053565663
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Entity Type | Individual
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Provider Name | KELLY ANN COPPOLA LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/10/2008
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Last Update Date | 02/28/2012
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Provider Practice Location Address
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Address Line | 1133 BROADWAY SUITE 1107
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City | NEW YORK
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State | NY
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Zip | 10010-7903
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Country | US
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Telephone | 646-457-1227
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Fax |
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Provider Business Mailing Address
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Address Line | 3177 30TH ST APT 3
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City | ASTORIA
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State | NY
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Zip | 11106-2801
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Country | US
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Telephone | 646-457-1227
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 72076937
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 078963
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License Number State | NY
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