Provider Demographics
NPI:1588736904
Name:COPPETO, SUSAN T
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:T
Last Name:COPPETO
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 1:68 CANNON DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:631-567-6721
Mailing Address - Fax:631-567-6721
Practice Address - Street 1:68 CANNON DRIVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741
Practice Address - Country:US
Practice Address - Phone:631-567-6721
Practice Address - Fax:631-567-6721
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0516961104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7484039OtherGHI VALUE OPTIONS
NY01612651Medicaid
NYP402169OtherOXFORD HEALTH INS
NY7484039OtherGHI VALUE OPTIONS
NYP402169OtherOXFORD HEALTH INS