MEDICARE: MS. H. DIANA KOPICKO LCSW

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	Q1-0000736	DE
2	1041C0700X	Clinical Social Worker	CW014576	PA
3	1041C0700X	Clinical Social Worker	44SC05239300	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2455127000	OTHER	DE	BCBS

General Provider Information

NPI Number	:	1598805582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. H. DIANA KOPICKO LCSW

Provider Business Mailing Address
First Line	:	2680 BOWERS BEACH RD
Second Line	:
City	:	FREDERICA
State	:	DE
Zip	:	19946-1335
Country	:	US
Telephone Number	:	302-335-4150
Fax Number	:	308-335-4150

Provider Business Practice Location Address
First Line	:	122 E CAMDEN WYOMING AVE
Second Line	:
City	:	CAMDEN
State	:	DE
Zip	:	19934-1302
Country	:	US
Telephone Number	:	302-335-4150
Fax Number	:	302-335-4150

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	07/09/2007

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