Provider Demographics
NPI:1619150299
Name:COPPOLO, JOSEPH JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:COPPOLO
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WILLIAM AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3142
Mailing Address - Country:US
Mailing Address - Phone:718-667-3790
Mailing Address - Fax:718-667-3790
Practice Address - Street 1:3 WILLIAM AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3142
Practice Address - Country:US
Practice Address - Phone:718-667-3790
Practice Address - Fax:718-667-3790
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010359103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical