Provider Demographics
NPI:1558444927
Name:COPELAND COUNSELING FOR YOUTH
Entity Type:Organization
Organization Name:COPELAND COUNSELING FOR YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:STAFFORD
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-243-1578
Mailing Address - Street 1:24 COPELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1529
Mailing Address - Country:US
Mailing Address - Phone:315-243-1578
Mailing Address - Fax:
Practice Address - Street 1:24 COPELAND AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077-1529
Practice Address - Country:US
Practice Address - Phone:315-243-1578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-22
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR066704-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty