Provider Demographics
NPI:1427295880
Name:COPELAND AVE COUNSELING LCSW PLLC
Entity type:Organization
Organization Name:COPELAND AVE COUNSELING LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:SLATER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:607-753-1611
Mailing Address - Street 1:24 COPELAND AVE
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1529
Mailing Address - Country:US
Mailing Address - Phone:607-749-5711
Mailing Address - Fax:
Practice Address - Street 1:24 COPELAND AVE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077-1529
Practice Address - Country:US
Practice Address - Phone:607-749-5711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100032108Medicare PIN