Provider Demographics
NPI:1972679231
Name:KOEPPEL, ELAINE (LCSW R031940)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:
Last Name:KOEPPEL
Suffix:
Gender:F
Credentials:LCSW R031940
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2437
Mailing Address - Country:US
Mailing Address - Phone:716-876-0584
Mailing Address - Fax:
Practice Address - Street 1:884 BRIGHTON RD
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-8169
Practice Address - Country:US
Practice Address - Phone:716-836-9460
Practice Address - Fax:716-836-9462
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0319401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00R031940Medicaid