Provider Demographics
NPI:1891366936
Name:OLD TOWN COUNSELING OF NEWBURGH LLC
Entity Type:Organization
Organization Name:OLD TOWN COUNSELING OF NEWBURGH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPATICH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:507-491-8887
Mailing Address - Street 1:PO BOX 1114
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47629-1114
Mailing Address - Country:US
Mailing Address - Phone:507-491-8887
Mailing Address - Fax:
Practice Address - Street 1:4333 OLD STATE ROUTE 261
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-2652
Practice Address - Country:US
Practice Address - Phone:507-491-8887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34008915AOtherLICENSE