Provider Demographics
NPI:1942773940
Name:KODOPIDIS, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KODOPIDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 WALNUT ST APT 2
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-5338
Mailing Address - Country:US
Mailing Address - Phone:732-604-9684
Mailing Address - Fax:
Practice Address - Street 1:2 INDUSTRIAL WAY W FL 2
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2265
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1106552101YS0200X
NJ37PC00889700106H00000X, 101YP2500X
NJ37AC00479600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37PC00889700Medicaid
NJ0029807Medicaid
NJ37AC00479600Medicaid