=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417954678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ERIN KOPREVICH CRC, LCSW-R
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2005
-----------------------------------------------------
Last Update Date | 10/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2680 GRAND ISLAND BLVD
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14072-1693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-573-7026
-----------------------------------------------------
Fax | 716-773-5642
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1961 HARVEY RD
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14072-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-573-7026
-----------------------------------------------------
Fax | 716-773-5642
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 058006
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------