MEDICARE: MRS. MARY ERIN KOPREVICH CRC, LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	058006	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	213352471	OTHER	NY	UNITED BEHAVIORAL HEALTH
2	6213037	OTHER	NY	INDEPENDENT HEALTH
3	000 2731 6601	OTHER	NY	UNIVERA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000 528 268 001	OTHER	NY	BC BS OF WNY

General Provider Information

NPI Number	:	1417954678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ERIN KOPREVICH CRC, LCSW-R

Provider Business Mailing Address
First Line	:	1961 HARVEY RD
Second Line	:
City	:	GRAND ISLAND
State	:	NY
Zip	:	14072-2108
Country	:	US
Telephone Number	:	716-573-7026
Fax Number	:	716-773-5642

Provider Business Practice Location Address
First Line	:	2680 GRAND ISLAND BLVD
Second Line	:
City	:	GRAND ISLAND
State	:	NY
Zip	:	14072-1693
Country	:	US
Telephone Number	:	716-573-7026
Fax Number	:	716-773-5642

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2005
Last Update Date	:	10/14/2009

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