Provider Demographics
NPI:1558570879
Name:KOPEC, ANN MARIE MONICA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:MONICA
Last Name:KOPEC
Suffix:
Gender:F
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:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:LOPEZ
Mailing Address - State:PA
Mailing Address - Zip Code:18628
Mailing Address - Country:US
Mailing Address - Phone:570-430-0521
Mailing Address - Fax:
Practice Address - Street 1:400 3RD AVE
Practice Address - Street 2:315
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5816
Practice Address - Country:US
Practice Address - Phone:570-430-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW012145101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA634532Medicare ID - Type Unspecified