Provider Demographics
NPI:1437727591
Name:KOPERDA, NICOLE M (NCSP, MA/CAGS)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:KOPERDA
Suffix:
Gender:F
Credentials:NCSP, MA/CAGS
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SINGLEY
Mailing Address - Street 1:378 CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1601
Mailing Address - Country:US
Mailing Address - Phone:516-274-2076
Mailing Address - Fax:
Practice Address - Street 1:378 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1601
Practice Address - Country:US
Practice Address - Phone:516-274-2076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1082284103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool