Provider Demographics
NPI:1619324910
Name:KOPATICH, KELLY M (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:KOPATICH
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 1:4333 OLD STATE RD 261
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2655
Mailing Address - Country:US
Mailing Address - Phone:507-491-8887
Mailing Address - Fax:
Practice Address - Street 1:OLD TOWNE COUNSELING OF NEWBURGH, LLC
Practice Address - Street 2:4333 OLD STATE ROAD 261
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2655
Practice Address - Country:US
Practice Address - Phone:507-491-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IN34008915A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker