Provider Demographics
NPI:1073633327
Name:MINDY S KOPOLOW PSYD PA
Entity Type:Organization
Organization Name:MINDY S KOPOLOW PSYD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KOPOLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PSYD
Authorized Official - Phone:617-972-5055
Mailing Address - Street 1:400 W CUMMINGS PARK
Mailing Address - Street 2:SUITE 3400
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-6519
Mailing Address - Country:US
Mailing Address - Phone:617-972-5055
Mailing Address - Fax:617-972-5011
Practice Address - Street 1:400 W CUMMINGS PARK
Practice Address - Street 2:SUITE 3400
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6519
Practice Address - Country:US
Practice Address - Phone:617-972-5055
Practice Address - Fax:617-972-5011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA851101YM0800X
FLPY5819103TC0700X
MA8603103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54439OtherBLUE CROSS BLUE SHIELD
FL54439Medicare PIN