Provider Demographics
NPI:1508970302
Name:KOPACZ, KATHI L (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:KATHI
Middle Name:L
Last Name:KOPACZ
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 BALDRIDGE TER
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5858
Mailing Address - Country:US
Mailing Address - Phone:301-704-3546
Mailing Address - Fax:301-668-3076
Practice Address - Street 1:164 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6204
Practice Address - Country:US
Practice Address - Phone:301-704-3546
Practice Address - Fax:301-668-3076
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD042591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216631300Medicaid
DC491884Medicare ID - Type Unspecified
MD374SMedicare ID - Type Unspecified