Provider Demographics
NPI:1407119829
Name:KOPACZ, SVETLANA (MSED)
Entity Type:Individual
Prefix:MS
First Name:SVETLANA
Middle Name:
Last Name:KOPACZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 BRIGHTON 12 STREET, APT # 5E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:917-702-0636
Mailing Address - Fax:
Practice Address - Street 1:2990 BRIGHTON 12 STREET
Practice Address - Street 2:APT 5E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:917-702-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY569696111174400000X
NY569695111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist