Provider Demographics
NPI:1598905770
Name:COPPOLA, RAYMOND J (PHD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182-2513
Mailing Address - Country:US
Mailing Address - Phone:774-318-0850
Mailing Address - Fax:
Practice Address - Street 1:1 MARCUS BLVD STE 106
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5953
Practice Address - Country:US
Practice Address - Phone:774-318-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-27
Last Update Date:2019-02-27
Deactivation Date:2018-06-04
Deactivation Code:
Reactivation Date:2018-06-14
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY022676103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18684OtherBCBS
MA2220002001OtherBCBS
MA1306421Medicaid
MA1308785Medicaid