Provider Demographics
NPI:1235684747
Name:COPPADGE, DARYL PATRICK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:PATRICK
Last Name:COPPADGE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 SOUTH 17TH STREET
Mailing Address - Street 2:SUITE101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103
Mailing Address - Country:US
Mailing Address - Phone:215-545-7800
Mailing Address - Fax:215-545-7870
Practice Address - Street 1:770 WOODLANE RD
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3804
Practice Address - Country:US
Practice Address - Phone:609-267-5928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC014922001041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0043494Medicaid